Critical Concepts:

Shock

Inadequate peripheral perfusion where oxygen delivery does not meet metabolic demand

Adult vs Pediatric Shock - Same causes/different frequencies

Pediatric Shock

HypovolemiaMost common cause of pediatric shockSmall blood volumes (80cc/kg)

SepsisSecond most common cause of pediatric

shockImmature immune system

Pediatric Shock

CardiogenicPrimary pump failure – congenital heart

diseaseSecondary failure from:

○ Hypoxia○ Acidosis○ Hypoglycemia○ Hypothermia○ Drug toxicity

Pediatric Shock

NeurogenicRareLow incidence associated with low pediatric

spinal cord trauma rates

Pediatric Shock Early shock - Very difficult to detect Pediatric cardiovascular system

compensates well

Early Signs/SymptomsTachycardia - carry chart of normalsSlow capillary refill ( > 2 seconds)Pale or mottled skin, cool extremitiesTachypnea

Pediatric Shock

Late Signs/SymptomsWeak or absent peripheral pulsesDecreasing level of consciousnessHypotension

Hypotension = Pre-arrest State

Pediatric Shock Management Initial assessment may detect shock, but

not its cause When in doubt, treat for hypovolemia

Shock Management

AirwayOpen, clear, maintainNon-invasive (chin lift, jaw thrust)Invasive (endotracheal intubation)Trauma patient - ? C-spine injury

Shock Management

Breathing100% oxygen indicated for all shockVentilation

○ Reduce work of breathing○ Do not “fight” patient

Shock Management

CirculationApply cardiac monitorControl obvious hemorrhageElevate lower extremities

Shock Management

Fluid ResuscitationObtain Access quicklyConsider intraosseous accessFluid bolus: 20 ml/kg isotonic fluidMost common error--Too LITTLE fluidReassess for:

○ Improved perfusion○ Respiratory distress

Check blood glucose○ Give D25W if D-stick < 40 - 60

Disorders of Hydration

CausesVomitingDiarrheaFeverPoor oral intakeDiabetes mellitus

Disorders of Hydration

Mild dehydration ( <5% weight loss)Mild increased thirstSlight mucous membrane drynessSlight decrease in urinary frequencySlight increase in pulse rate

Disorders of Hydration

Moderate dehydration (5 - 10% weight loss)Moderate increase in thirstVery dry, “beefy red” mucous

membranesDecrease in skin turgorTachycardiaOliguria, concentrated urineSunken eyes

Disorders of Hydration

Severe dehydration (10 - 15% weight loss)Severe thirstTenting of skinNo tears when cryingWeak, thready pulsesMarked tachycardiaSunken fontanelleHypotensionDecrease in LOC

Disorders of Hydration Management

Oxygen20 cc/kg boluses LRRepeat boluses as needed to

○ Restore peripheral pulses○ Decrease tachycardia○ Improve LOC

Remember that hypotension is a late and ominous finding!

Reassess frequently

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Normal upper airway anatomy

Esophagus

Trachea

Epiglottis

Tonsils

TongueLarynx

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Typical causes of distress Upper airway

CroupRetropharyngeal abscessEpiglottitisForeign body aspiration

Lower airwayReactive airway disease / asthmaBronchiolitisPneumoniaPneumothorax

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Why are kids different? Obligate nose-

breathers Tongue relatively

larger Higher larynx (C3-

C4 versus C6) Narrowing of

airway causes exponential rise of airway resistance

Less elasticity of alveoli

Lower FRC Diaphragm

FlatterMuscle fibers more

vulnerable to fatigue Chest wall

More compliantRibs more horizontal

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Signs & symptoms of distress Nasal flaring Hypoventilation,

apnea Stridor Grunting Wheezing Pallor, ashen color WOB Tachypnea

Cyanosis Head bobbing Tripod positioning Retractions Level of

consciousness Air movement Acidosis Hypercapnea

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Croup (LLaryngoTTracheoBBronchitis)

Most severe in kids 6 mo - 3 years old Males Winter months Associated illnesses

Ear infectionPneumoniaOrganisms: parainfluenza types 1, 2 & 3,

adenovirus, RSV, influenza

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Croup symptoms

URI symptoms X 1-3 days

Low grade fever “Barking” cough,

hoarseness Inspiratory stridor Worse at night Prefer to sit up Aggravated by

agitation & crying

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Croup diagnosis

Clinical diagnosis Does not require

neck X-rayConsider X-ray in

patients with atypical presentation or clinical course

“Steeple sign”

Steeple sign

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Croup treatment

Position of comfort, with parent Dexamethasone 0.6 mg/kg IV/IM Epi neb Heliox SQ Epi Cool mist

Hypopharnyx

Narrow air column

Trachea

Steeple sign

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Retropharyngeal abscess

Deep, potential, space of the neck Children age 6 months to 6 years Other deep neck abscesses more

frequent in older children & adultsParapharyngealPeritonsillar

Potential for airway compromise Complications secondary to mass effect,

rupture of the abscess, or spread of infection

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Retropharyngeal abscess - symptoms Fever, chills,

malaise Decreased appetite Irritability Sore throat Difficulty or pain

swallowing Jaw stiffness Neck stiffness

Muffled voice “Lump” in the throat Pain in the back &

shoulders upon swallowing

Difficulty breathing is an ominousominous complaint that signifies impending airway obstruction

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Retropharyngeal abscess

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Retropharyngeal abscess Polymicrobial infection typical

Gram-positive organisms and anaerobes predominating

Gram-negative bacteria possibleOropharyngeal flora

Most common cause is group A beta-hemolytic streptococci

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Retropharyngeal abscess - Treatment

Position airway - comfort Avoid unnecessary manipulation Monitor, CT of neck, possible OR Sedation & paralytics can relax airway

muscles, leading to complete obstruction

Endotracheal intubation is dangerous Abx: clindamycin, cefoxitin, Timentin,

Zosyn, or Unasyn

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Epiglottitis

Acute, rapidly progressive cellulitis of the epiglottis and adjacent structures

Before immunization - peak incidence at 3.5 years of age

Danger of airway obstruction - medical emergency

Prompt diagnosis and airway protection required

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Epiglottitis - signs & symptoms

More acute presentation in young children than in adolescents or adults

Symptoms for <24 hrsHigh fever, severe sore throat, tachycardia,

systemic toxicity, drooling, tripod position

Moderate or severe respiratory distress with inspiratory stridor & retractions

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Epiglottitis - lateral neck film

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Epiglottitis

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Epiglottitis - etiology

Group A Streptococcus Other pathogens seen less frequently

include:Strep pneumoniaeHaemophilus parainfluenzaStaph aureus

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Epiglottitis - Treatment

Position of comfort, with parent Minimize manipulation Intubation under controlled

circumstances O2 prn, blow-by if not tolerating mask Avoid agitation (Do not try to start IV,

obtain blood or examine airway!) Consult anesthesia & ENT IV for antibiotics, after airway secure

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Foreign body (FB) aspiration

Toddler through preschool age commonNo molar teeth for thorough chewingTalking, laughing, and running while eating

Nuts, raisins, sunflower seeds, pieces of meat and small smooth (grapes, hot dogs, & sausages)

Dried foods absorb water

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Foreign Body aspiration

Sudden episode of coughing / choking while eating with subsequent wheezing (sometimes unilateral), coughing, or stridor

Tragic cases occur with total or near-total occlusion of the airway

Frequent sites of FB lodgement:Usually below vocal cordsMainstem bronchiTracheaLobar bronchi

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Foreign Body aspiration

Extrathoracic FB:Breath sounds are inspiratoryinspiratory

Intrathoracic FBNoises are symmetricsymmetric but more prominent in

central airwaysIf FB is beyond the carina, the breath

sounds are usually asymmetricasymmetric○ Kid chest transmits sounds well○ Stethoscope head may be bigger than lung lobes○ Lack of asymmetry should not dissuade you from

considering the FB diagnosis

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Foreign Body aspiration

Hyperinflation & air-trapping of the affected lobe(s) is typicalBest seen with X-ray taken at expirationDifficult in little kids

May see soft tissue opacity in proximal airway

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Foreign bodies

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FB aspiration

Position of comfort Heimlich maneuver, back blows BVM prn Magill forceps (if object above cords) Intubation prn Needle cricothyrotomy Surgical cricothyrotomy Rigid bronchoscopy for FB removal

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Reactive airway disease / Asthma

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RAD / Asthma - children <3 years - small intrapulmonary airways Poor collateral ventilation Decreased elastic recoil pressure Partially developed diaphragm

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RAD / Asthma Identify and remove asthma triggers Albuterol, nebulized Ipratopium bromide (Atrovent) Methylprednisolone (Solumedrol) Magnesium sulfate CPAP / BiPAP Heliox Epinephrine or terbutaline infusion May require inubation At risk for pnuemothorax due to hyperinflation

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Bronchiolitis

Organisms: RSV most commonOthers: parainfluenza, influenza, human

metapneumovirus (hMPV), adenovirus, mycoplasma

Winter & spring Males Typically <2 years old, peak 2-8 mos Disease more severe in babies 1-3 mo old Risk factors: Heart disease, BPD,

prematurity, smoking in home

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Bronchiolitis

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Bronchiolitis - symptoms

Apnea, bradycardia Desaturations Cough, copious secretions Tachypnea, tachycardia Crackles, wheezing Increased WOB, retractions Flaring, grunting Pallor, cyanosis

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Bronchiolitis - diagnosis No diagnostic tests needed, but possibly:

Rapid viral panel (antigen or FA panel)Viral culturesCXR - hyperinflation, peribronchial cuffing, patchy

atelectasis Tachypnea, WOB, wheezing Hx URI

fever, cough, runny nose, appetite Apnea (may occur w/o other symptoms) May be complicated by secondary bacterial

infection

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Bronchiolitis

Isolation - contact, droplet O2, keep sats ≥92%

Pulmonary toilet, suctioning! CPAP / BiPAP No steroids Nebs largely unhelpful (<1/3) Chest PT prolongs hospitalization Antibiotics depend on other sxs

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Pneumonia Types:

Bronchopneumonia - lobar consolidation

Interstitial - usually viral More common in infants & toddlers

than in adolescents Commonly:

Viral, pneumococcus, MycoplasmaIn immunocompromised, anything is

possible!

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Pneumonia - symptoms

Cough Tachypnea Grunting Retractions Chest pain Vomiting, poor feeding, abdominal pain Fever depends on type

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Pneumonia

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Pneumonia – Initial Treatment O2, keep sats ≥92%

CPAP, BiPAP Antibiotics, if considered bacterial

Cefotaxime + vancomycinAzithromycin

Monitor mental status Intubate & ventilate if respiratory failure Complications: effusion, abscess

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Pneumothorax

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Pneumothorax radiographs

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Tension PTX

NormalNormal

Tension PTXTension PTXPTXPTX

R L

heartheart

LungLung

HeartHeartAirleakAirleak