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 • Respiratory failure • 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; pneumonia, drowning, pulmonary contusion School-aged child 70 to 120 – Crackles: 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 37.1C, 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 38.4C, 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 –Croup 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 radiography of neck performed on cases in which diagnosis was in question may show a Steeple sign. Steeple Sign Differential Diagnosis: What Else? • Epiglottitis (rare) • Bacterial tracheitis • Peritonsillar abscess • 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