Aims

Diagnostic Approach to Pediatric • Pediatric Assessment Emergencies • Respiratory Emergencies • Shock

新光醫院急診醫學科 • Cardiac Rhythm Disturbances 吳柏衡醫師 • Emergency Procedures 103.09.11

Pediatric assessment

• Initial assessment –PAT Pediatric Assessment –ABCDE • Cardiovascular assessment – Vital signs – End-organ perfusion

Pediatric Assessment Triangle Appearance

Work of • Tone Appearance Breathing • Interactiveness • Consolability • Look/Gaze • Speech/Cry Circulation to skin Work of Breathing Circulation to Skin

• Abnormal airway • Pallor sounds • Mottling • Abnormal • Cyanosis positioning • Retractions • Nasal flaring • Head bobbing

Case Study 1: Pediatric Assessment Triangle “Cough, Difficulty Breathing”

Breathing • One-year-old boy presents with complaint Appearance Audible of cough, difficulty breathing. Alert, smiling, inspiratory • Past history is unremarkable. He has had nontoxic stridor at rest nasal congestion, low grade fever for 2 days. Circulation Pink

Pediatric Assessment Triangle: Questions Respiratory Distress

What information does the PAT tell you Breathing Appearance about this patient? Abnormal Normal

What is your general impression?

Circulation Normal General Impression

• Stable • Respiratory distress • • Shock (compensated/decompensated) • CNS or Endocrine dysfunctions • Cardiopulmonary failure/arrest

Case Progression/Outcome Initial assessment-ABCDE

• Initial assessment: Respiratory distress • Airway with upper airway obstruction • Breathing • Initial treatment priorities: • Circulation – Leave in a position of comfort. • Disability – Obtain oxygen saturation. • Exposure – Provide oxygen as needed. – Begin specific therapy.

Airway Breathing: Respiratory Rate Age Respiratory Rate • Manual airway opening maneuvers: Head tilt- Infant 30 to 60 chin lift, jaw thrust Toddler 24 to 40 • Suction: Can result in dramatic improvement in Preschooler 22 to 34 infants School-aged child 18 to 30 • Age-specific obstructed airway support: Adolescent 12 to 16 – <1 year: Back blow/chest thrust – >1 year: Abdominal thrust • Slow or fast respirations are worrisome. • Advanced airway techniques Breathing: Auscultation Circulation: Heart Rate Age Normal Heart Rate • Listen with stethoscope over midaxillary line and Infant 100 to 160 above sternal notch – Stridor: Upper airway obstruction Toddler 90 to 150 – Wheezing: Lower airway obstruction Preschooler 80 to 140 – Grunting: Poor oxygenation; , drowning, School-aged child 70 to 120 – : Fluid, mucus, blood in airway Adolescent 60 to 100 – Decreased/absent breath sounds: Obstruction

Circulation Hypotension (SBP, mmHg) • Newborn (0-28 days): < 60 • Pulse quality: Palpate central and • Infant: < 70 peripheral pulses • Child (1-10): < 70 + (age x 2) • Skin temperature: Reverse thermometer • Child (> 10): < 90 sign • Capillary refill • Blood pressure: Minimum BP = 70 + (2 X age in years)

Pediatric Vital signs Disability

HR RR BP 0-1 y/o 100-160 30-60 60-70 • Quick neurologic exam 1-6 y/o ~140 20-40 70 + Age*2 6-12 y/o ~120 15-30 70 + Age*2 • AVPU scale: >12 y/o 60-100 20 > 90 –Alert – Verbal: Responds to verbal commands – Painful: Responds to painful stimulus – Unresponsive • (Pediatric) Glasgow Coma Scale Exposure End-organ perfusion

• Proper exposure is necessary to evaluate • Skin: temperature, color, capillary refilling physiologic function and identify anatomic time abnormalities. • Brain: level of consciousness • Maintain warm ambient environment and minimize heat loss. • Kidney: urine output • Monitor temperature. • Warm IV fluids.

Respiratory Emergencies

Case Study 1 Initial Assessment (1 of 2)

• Mother of 13-month-old boy found him PAT: choking and gagging next to container of – Normal appearance, abnormal breathing, spilled nuts. normal circulation • Paramedics noted appearance is alert; Vital signs: work of breathing is increased with – HR 160, RR 60, BP 88/56, T 37.1C, O2 sat 93%, Wt audible stridor; subcostal retractions; color 11 kg is normal. Question General Impression

What is your general impression of this • Respiratory distress: patient? – Upper airway obstruction – Foreign body aspiration

What are your initial management priorities?

Initial Assessment (2 of 2) Management Priorities

A: Stridor • Patient is brought to monitored bed and B: Tachypneic with retractions, reduced tidal volume allowed to remain in position of comfort. C: Color is normal, skin is warm and dry, • Supplemental oxygen is provided. pulse is rapid but strong and regular. D: Alert with no focal neurologic signs; • IV access is deferred to avoid agitation. GCS 15 • Specialists are contacted. E: No obvious signs of injury

Your First Clue: Discussion: Foreign Body Aspiration Foreign Body Aspiration

• A history of choking is the most reliable • Background: predictor of FB aspiration. – 150-300 fatalities in young children each year. • Other signs and symptoms include: – 2/3 of cases are in children 1-2 years of age. – Upper airway: Stridor, respiratory or cardiopulmonary arrest – Lower airway: Coughing, wheezing, retractions, decreased breath sounds, cyanosis Background: Background: Foreign Body Aspiration (1 of 2) Foreign Body Aspiration (2 of 2)

• Foreign objects can be lodged in the • Food items are the upper or lower airway, or esophagus. most commonly Differences in the pediatric airway make aspirated FB. • evaluation and management of foreign • Balloons are the body aspiration challenging. most common FB to result in death.

Diagnostic Studies

• Radiology – Radiopaque FBs are seen in about 15% of cases. – Other findings seen in lower airway FB aspiration on chest radiograph • Air trapping/hyperinflation • Pulmonary consolidation • Barotrauma

Radiology Management (1 of 6)

• In this chest • Upper airway FB: radiograph, FB – If patient is able to cough or speak: aspiration is suggested • Leave in a position of comfort. as the left side of the • Provide supplemental oxygen. chest is hyperlucent • Consider heliox therapy from air trapping. • Priority to get patient to operating room for removal Management (2 of 6) Management (3 of 6)

• Upper airway: • BLS: – With severe partial or complete airway – Infant: 5 back blows/5 chest thrusts obstruction, management depends on age. – Management options can be divided into basic life support (BLS) and advanced life support (ALS).

Management (4 of 6) Management (5 of 6) • BLS: –Child: 5 abdominal • ALS: thrusts – Laryngoscopy and removal with pediatric Magill forceps

Management (6 of 6) Case Progression/Outcome

• Lower airway FB: • Patient was taken to operating room – Heliox may be tried as a temporizing measure where rigid bronchoscopy was performed prior to removal for patients in severe and a peanut was removed from the respiratory distress. subglottic airway. – Bronchoscopy and removal of FB in operating room • FB retrieval rate approaches 100%. Case Study 2 Initial Assessment (1 of 2)

• 15-month-old boy with a history of cold PAT: for 2 days develops a barking cough. – Normal appearance, abnormal breathing, • He tracks you with his gaze as you normal circulation approach. Vital signs: • He has stridor at rest, retractions, and has – HR 180, RR 60, T 38.4C, O2 sat 91% on cyanosis around his lips. blow-by oxygen, Wt 10 kg

Question General Impression

What is your general impression of this • Respiratory distress: patient? – Upper airway obstruction –

What are your initial management priorities?

Initial Assessment (2 of 2) Management Priorities

A: Stridor at rest • Leave patient in a position of comfort. B: Tachypnea, retractions • Place patient on cardiorespiratory monitor. C: Slight cyanosis around the lips, • Administer nebulized epinephrine. otherwise color is normal, capillary refill • Administer corticosteroids IM. <2 seconds, skin warm and dry, pulse strong and rapid D: Alert, GCS 15 E: No signs of injury, no rash Your First Clue: Croup Background: Croup

• Prodromal symptoms mimic upper • Croup, or laryngotracheobronchitis, is respiratory infection. common in infants and children. • Fever is usually low grade (50%). – Affects children 6 months to 6 years – Incidence 3-5/100 children • Barky cough and stridor (90%) are – Peak in second year of life common. – Seasonal: Occurs in fall and early winter • Hoarseness and retractions may also occur. – Viral etiology most common: Parainfluenza virus

Diagnostic Studies

• The diagnosis of croup is made clinically. • Routine laboratory or radiological studies are not necessary. • Plain of performed on cases in which diagnosis was in question may show a .

Steeple Sign Differential Diagnosis: What Else?

• (rare) • Bacterial • • Uvulitis • Allergic reaction • Foreign body aspiration • Neoplasm Management Options: Croup Management Options: Croup (1 of 3) (2 of 3)

• Humidified oxygen • Steroids – Theoretical benefit – literature suggests NO – No significant difference in outcome between significant benefit dexamethasone and budesonide • Steroids – Dexamethasone – Faster improvement with croup score, • Doses 0.15-0.6 mg/kg PO or IM are effective. decrease in endotracheal intubation, and –Budesonide shorter hospital stays • Dose 2mg/2mL nebulized

Management Options: Croup Case Progression/Outcome (3 of 3)

• Epinephrine • 15-month-old patient received inhaled – Begin epinephrine for signs of moderate to epinephrine and dexamethasone IM. severe respiratory distress. • He was observed in the ED for 3 hours. • Racemic 0.05 mL/kg (max 0.5 mL) At the time of discharge, his respiratory • L-epinephrine (1:1,000 solution) 0.5 mL/kg (max 5 • mL) rate was 40 breaths/min and O2 sat was – Observe patients receiving epinephrine for a 97% on room air. minimum of 3 hours before discharge.

Stridor in children > 6 m/o Common pediatric respiratory emergency • Upper Airway –Croup Shock –FB aspiration – – Epiglottitis –Anaphylaxis • Lower airway – Bronciolitis – – pneumonia

Pathophysiology of Shock Shock

Preload • Inadequate tissue perfusion (delivery of Contractility Afterload Stroke oxygen and nutrients) to meet the Volume Cardiac Blood metabolic demands of the body. Output Flow Heart Rate Oxygen Delivery to Tissues Hemoglobin (Hgb) Concentration Blood Oxygen Oxygen Bound to Hgb Content Oxygen Dissolved in Plasma

S/S Hypovolemic Shock

• Early S/S: Tachypnea, Tachycardia, • Fluid loss: Mottling or pallor skin, Prolonged – Diarrhea, vomiting, anorexia, diuresis capillary refilling time – Hemorrhage • Late S/S: Altered consciousness, • Resuscitation: Hypotension, Respiratory failure, – Fluid replacement Oligouria, Cyanosis – NS or LR 20 mL/kg bolus infusions, reassess, repeat as needed – Blood transfusion for excessive hemorrhage Cardiogenic Shock Distributive Shock

• Poor myocardial contractility or impaired ejection: • Inappropriate vasodilation with maldistribution – Cardiomyopathy, congenital heart disease, of blood flow: myocarditis, congestive heart failure, arrhythmia – Anaphylactic shock, spinal cord injury, septic shock – “Warm shock” • Resuscitation: • Resuscitation: – Fluid bolus (10 mL/kg) and reassess – Vasoconstrictors (e.g., epinephrine) – Inotropes, pressors (e.g., dopamine, dobutamine, – Anaphylaxis treatment epinephrine) – Spinal cord injury treatment – Sepsis treatment

Septic Shock Obstructive shock

• Elements of distributive shock, cardiogenic shock • Tension / Cardiac and hypovolemic shock: – Inappropriate vasodilation with a maldistribution of tamponade blood flow • Resuscitation: – Myocardial depression – Fluid bolus – Relative hypovolemia – Emergency decompression • Resuscitation: – Fluid bolus – Pressors and inotropes – Antibiotics

Compensated vs Decompensated Compensated Shock Appearance Work of Breathing Tachypnea Alert, anxious • Compensated: – Vital organs continue to be perfused by compensatory Circulation mechanisms. tachycardia, decreased peripheral pulses, cool or pale skin – Blood pressure is normal. Decompensated Shock • Decompensated: – Compensatory mechanisms are overwhelmed and Appearance Work of Breathing inadequate. Altered mental status Tachypnea, bradypnea – Hypotension, high mortality risk • Aggressive treatment of early shock: Circulation – Halts progression to decompensated shock Tachycardia/ bradycardia, absent peripheral pulses, mottled/cyanotic skin 7-month-old boy Initial assessment-PAT

Appearance • Diarrhea and vomiting x 24 hrs Work of Breathing Alert: Eyes open, Tachypnea • Fever looks at father and • Poor intake around room • Fussier than usual Circulation • Decreased urine output: 1 wet diaper in Skin: pallor, slightly mottled 12 h

Initial assessment-ABCDE

• Airway: patent • Breathing: tachypnea; no stridor or What is general impression? wheezing, no retraction  O2 delivery • Circulation: Cool; Capillary refilling time: Compensated shock 3-4 seconds IV & Monitor • Disability: alert • Exposure: no wound

Vital signs Differentiate diagnosis • HR 200; BP 74/35; RR 40; BT 37.3oC; weight 6 kg • Hypovolemic shock • The common causes What is your differentiate diagnosis and – Acute enterocolitis management priorities? – Hemorrhagic shock by trauma – DKA with dehydration Management Priorities

• ABCDE • O2/ IV/ Monitor • Isotonic fluid resuscitation – 20 mL/kg NS rapid bolus – Reassessment • Obtain laboratory studies and cultures

Stable Versus Unstable

• Unstable rhythm require emergency therapy Cardiac Rhythm Disturbances – Rhythm that may cause and deteriorate circulatory instability

Assessment of cardiovascular Circulatory instability function

• Compensated shock • Assess ventilation, heart rate, end-organ • Decompensated shock (hypotension) perfusion, peripheral pulse, blood – Poor end-organ perfusion pressure – Altered consciousness • Is cardiovascular instability present? • Cardiopulmonary arrest • Is CPR needed? Rhythm groups by pulse rate Definitions of rhythm groups Rate Infant Child • Slow pulse rate = bradyarrhythmia • Fast pulse rate = tachyarrhythmia Fast >220 >180 • Absent pulse= pulseless arrest = collapse rhythm Slow <80 <60

Assessment of cardiac rhythm Diagnosis? groups

• Is the pulse rate slow, fast, or absent ? • Is perfusion compromised ? • Are the ventricular complexes wide or narrow ? • Is there a diagnostic pattern to the ECG ?

Fast pulse- narrow ventricular complex- SVT vs ST

• ST • SVT – History compatible with – History incompatible ST (eg, fever, dehydration, pain) with ST – P waves present/ normal – P waves absent/ – Heart rate often varies abnormal with activity – Heart rate does not – Infant: HR< 220 bpm vary with activity – Child: HR< 180 bpm – Infant: HR> 220 bpm – Child: HR> 180 bpm Management of SVT Sinus Tachycardia

• Poor perfusion – Vagal manevers – Immediate electrical cardioversion (0.5-1J/Kg, up to 2J/Kg) – Chemical cardioversion (adenosine) • Adequate perfusion – Vagal maneuvers – Chemical cardioversion – Electrical cardioversion

Paroxysmal Supraventricular Ventricular tachycardia Tachycardia

• Monomorphic VT • Polymorphic VT (Torsades de Pointes)

Ventricular tachycardia Polymorphic VT Management of monomorphic VT Management of polymorphic VT

• Poor perfusion – Synchronized cardioversion (0.5-1 J/Kg) – Synchronized cardioversion (0.5-1 J/Kg) – Use of pharmacologic agent –MgSO4 25-50 mg/ Kg, up to 2g • Amiodarone 5mg/Kg IV over 20-60 mins • Procanamide 15mg/Kg IV over 30-60 mins – Identify and treat the underlying cause – Identify and treat the underlying cause • Adequate perfusion (congenital condition, electrolyte imbalance, – Use of pharmacologic agent drug toxicity) • Amiodarone 5mg/Kg IV over 20-60 mins • Procanamide 15mg/Kg IV over 30-60 mins – Synchronized cardioversion (0.5-1 J/Kg) – Identify and treat the underlying cause

Pulseless Arrest Case 5: Asystole?

• VF • Pulseless VT • PEA • Asystole VF Pulseless Arrest*

VF/VT Not VF/VT

Shock x 1 (2J/kg) Vasopressor

CPR 2 mins/ Vasopressor (Drug - Shock) CPR

Shock x1 (4J/Kg) *CPR and seek reversible Anti-arrhythmic causes throughout

Potentially reversible causes of life- threatening arrhythmia

• 6 H’s • 6 T’s – Hypoxemia – Tamponade – Hypovolemia – Tension pneumothorax – Hypothermia –Tablets – Hypo-/Hyperkalemia – Thrombosis (AMI) –Hydrogen ion – Thrombosis (PE) – Hypo-/Hyperglycemia –Trauma

PEA 找原因 • 臨床: 問病史 看聽敲( 兩心兩肺) 毒抽血 超音波

• 6H6T???? • 但小孩有多少有CAD?(小心 kawasaki..), 誰家小孩 • 背不起來,怎麼辦? 誰來教我口訣? 有pulmonary embolism? 沒有超音波誰敢戳 pericardial effusion, PEA怎麼聽distant heart • 兩心兩肺低氧高鉀酸藥威  口訣是考 sound?  所以 只要考慮tension PTX! 試用跟唬濫用的(可以在十秒內講出來 …) • 創傷? 眼睛不會看啊! 會死的創傷 internal bleeding, , PTX 超音波!!

• Shaken baby syndrome? 先救活病人再說吧! 問 病史!! Emergency Procedures

• 低血氧? 還要你說! ETT 早就on 好了 • Endotracheal intubation (RSI) • 低血容? 還要你說! IV NS full run, 超音波 輸血? • Defibrillation and Cardioversion • 酸,高低鉀, 低血糖  抽血! • 毒物, 低體溫  history • Intraosseous access • 總結:PE(看聽敲) – tension PTX 病史 – 毒傷溫 抽血 – 鉀糖酸 超音波 – 兩心兩肺 傷

Endotracheal intubation Basic RSI

• RSI • Airway assessment • Preoxygenation • SOAP-ME • Optional adjunctive agents (atropine, lidocaine) • Tracheal tube size = 4 + age/4 • Sellick maneuver (cricoid pressure) • Tracheal tube depth at lip = 3 x TT size • Paralyzing agent • Sedative agent • Intubation and confirmation

Adjunctive Agents Sedative Agents

• Atropine – anticholinergic • No perfect sedative – Probably useful in all children • All sedatives may cause cardiovascular – Prevents bradycardia during intubation compromise. – Reduces oral secretions (e.g., ketamine) • Selection is dependent upon clinical conditions. • Lidocaine – lowers intracranial pressure • To simplify things, consider etomidate to be – Given IV “default” sedative. – Might be beneficial in head trauma cases or when ICP elevation is suspected Thiopental Midazolam

• Onset: 30 to 40 sec • Onset: 1 to 2 min • Duration: 10 to 30 min • Duration: 20 to 30 min • Benefits: Lowers ICP, lowers cerebral • Benefits: Reversible, amnestic, anticonvulsant, metabolism and oxygen demand, anticonvulsant less likely to cause myocardial depression • Cautions: Myocardial depression. Giving this • Cautions: Variable dose to achieve slowly reduces this adverse effect. Avoid in unconsciousness. Titration is required, which is hypotension or patients in shock. May not suitable for RSI. RSI requires a single dose. occasionally cause .

Ketamine Etomidate

• Onset: 1 min • Onset: Less than 1 min • Duration: 30 min • Duration: 10 to 20 min • Benefits: Bronchodilator, sympathomimetic, less • Benefits: Lowers ICP, supports blood pressure likely to cause myocardial depression. • Cautions: Myoclonic excitation (might resemble • Cautions: Inject slowly to avoid vomiting; seizures), immunosuppression increases oral secretions (use atropine as an adjunctive agent), increases ICP, might cause emergence reactions

Sedative Selection Paralyzing Agents

• Hypotension: Etomidate • Also called muscle relaxants • Status asthmaticus: Ketamine • Succinylcholine • Head injury without hypotension: – Onset 30-60 sec, duration 3-8 min Thiopental or etomidate – Shorter duration, higher risk of adverse effects • Unconscious in shock: Any agent may • Rocuronium adversely affect circulation. Consider using – Onset 1-3 min, duration 30-45 min no sedative or a low dose in conjunction – Longer duration, but less potential for adverse effects with shock resuscitation. Succinylcholine Rocuronium

• “Depolarizing” muscle relaxant • “Nondepolarizing” muscle relaxant, no fasciculations. – Depolarizes muscle first (causing “fasciculations”), • Other drugs in group: vecuronium, pancuronium, then paralysis atracurium, mivacurium. Rocuronium has the fastest – Fasciculations may cause muscle pain and onset time and fewest adverse effects. myoglobinuria, more common in muscular adults • Onset time is slower than succinylcholine, but in practice, • Higher risk of hyperkalemia, especially following burns intubation initiated at 60-90 sec after administration, and/or crush injuries slightly slower than succinylcholine. • Higher risk of malignant hyperthermia • Longer duration (30-45 min) in case intubation is not • Fastest onset time, short duration (3-8 min) in case intubation is not achieved achieved. Partially reversible with edrophonium.

Defibrillation and Paralyzing Agent Selection Cardioversion

• Physician preference • Onset time: Succinylcholine faster • Duration: Succinylcholine shorter • Adverse effects: Fewer with rocuronium • Intubation conditions: Approximately the same

Intraosseous access • Ch 113 fever and serious bacterious illness • Ch119 stridor and drooling • Ch120 wheezing • Ch 121 pneumonia • Ch124 acute abdomen in children