GEMC: Pediatric Respiratory Emergencies: Resident Training
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Project: Ghana Emergency Medicine Collaborative Document Title: Respiratory Emergencies, 2013 Author(s): Jeff Holmes MD, Maine Medical Center License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
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Pediatric Respiratory
Emergencies
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Objectives
• Differentiate between the categories of respiratory dysfunction
• Describe the assessment of a child with respiratory compromise
• Determine the treatment priorities for pediatric patients with respiratory emergencies
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9-month-old infant
You are dispatched to the scene of a 9-month-old infant with difficulty breathing and fever.
What important information must you gather from the history and assessment?
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Key Respiratory History
• Previous history of similar events • Current medications • History of recent fever • Onset • History of injury
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Initial Assessment: Pediatric Assessment Triangle (PAT)
Assess for: – Abnormal appearance – Abnormal work of breathing
• Abnormal positioning • Abnormal airway sounds • Retractions • Nasal flaring
– Abnormal color
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Initial Assessment: ABCDE’s
Assess for: – Airway patency – Respiratory rate – Air movement/chest rise – Breath sounds – Oxygen saturation
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9-month-old infant
Circulation to Skin Normal color
Work of Breathing Retractions, nasal flaring
Appearance Alert, looking around, crying
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Initial Assessment
• Airway - Open • Breathing - RR 80 breaths/min,
wheezing with good air movement, SaO2 90%
• Circulation - HR 180 beats/min; skin warm and normal color; CRT normal
How sick is this infant?
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• Moderate to severe respiratory distress What are the categories of respiratory
dysfunction?
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Categories of Respiratory Dysfunction
• Respiratory distress: Increased work of breathing to maintain adequate oxygenation, ventilation
• Respiratory failure: Compensatory mechanisms fail, inadequate oxygenation and/or ventilation
• Respiratory arrest: Absence of breathing
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Causes of Respiratory Dysfunction
Anatomic Problem Physical Sign • Upper airway obstruction
• Stridor
• Lower airway obstruction
• Wheezing
• Disease/fluid of the lungs (alveoli)
• Crackles
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Which common diseases cause lower airway obstruction in infants and children?
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Diseases Causing Lower Airway Obstruction
• Asthma: Inflammatory reaction of small airways
– Bronchoconstriction, edema, increased mucus • Foreign body aspiration:
Mechanical obstruction of bronchi – Sudden choking, coughing, wheezing
• Bronchiolitis: Infection of bronchioles
– Bronchoconstriction, edema, increased mucus Why is this child wheezing?
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• History of fever, wheezing and development of respiratory distress over 2 days suggest lower airway obstruction (bronchiolitis) • Begin treatment on scene
What are your treatment and transport priorities for this patient?
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Treatment Priorities
– Leave patient in a position of comfort
– Provide oxygen as tolerated
– Transport
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How can you distinguish respiratory distress from respiratory failure in a patient with lower airway obstruction?
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Respiratory Failure
• Abnormal appearance • Respiratory rate extremely high or low • Tachycardia or bradycardia
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• Infant transported with blow-by oxygen • Nebulized albuterol given by ALS
providers • Condition improved on arrival in the
emergency department
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4-year-old child
• You are dispatched to the scene of a 4-year-old child with trouble breathing.
• Mother states that he was playing with a small superball prior to collapsing.
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4-year-old child
Circulation to Skin Pale skin color
Work of Breathing Stridor, severe retractions
Appearance Unresponsive, poor muscle tone
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Initial Assessment
– Airway - Obstructed – Breathing - RR 12 breaths/min, decreased
breath sounds, little or no chest rise, unable to speak or cry
– Circulation - HR 100 beats/min and dropping; pulses present; BP deferred
– Disability - AVPU=U – Exposure - No sign of trauma
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How sick is this child? What is the cause of this child’s respiratory dysfunction?
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• Critical patient in respiratory failure from upper airway obstruction due to foreign body aspiration
What are your treatment and transport priorities?
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• Open mouth, remove foreign body if visible
• Attempt BVM ventilation, if no chest rise, perform 5 abdominal thrusts
• Repeat assessment and treatment
• Transport or ALS intercept
Treatment Priorities
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Case Progression • Abdominal thrusts fail to dislodge foreign body • ALS providers remove superball with pediatric
Magill forceps • Patient requires BVM ventilation for 3-4 minutes • Patient alert and active on arrival to the
emergency department
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Conclusion
• The degree of respiratory dysfunction drives treatment priorities.
• Identification of the cause of the dysfunction may be determined from the history and physical examination and can dictate specific treatment.
• Always begin with BLS airway/breathing management.
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Conclusion
• Consider ALS interventions if the child does not improve rapidly with BLS.
• Reassess and be prepared to modify the treatment plan during transport.