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Critical Concepts:. Recognition and Initial Management of Pediatric Shock and Respiratory Failure. Shock. Inadequate peripheral perfusion where oxygen delivery does not meet metabolic demand Adult vs Pediatric Shock - Same causes/different frequencies. Pediatric Shock. Hypovolemia - PowerPoint PPT Presentation
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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
ACCT4Kids 18
Normal upper airway anatomy
Esophagus
Trachea
Epiglottis
Tonsils
TongueLarynx
ACCT4Kids 19
Typical causes of distress Upper airway
CroupRetropharyngeal abscessEpiglottitisForeign body aspiration
Lower airwayReactive airway disease / asthmaBronchiolitisPneumoniaPneumothorax
ACCT4Kids 20
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
ACCT4Kids 21
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
ACCT4Kids 22
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
ACCT4Kids 23
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
ACCT4Kids 24
Croup diagnosis
Clinical diagnosis Does not require
neck X-rayConsider X-ray in
patients with atypical presentation or clinical course
“Steeple sign”
Steeple sign
ACCT4Kids 25
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
ACCT4Kids 26
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
ACCT4Kids 27
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
ACCT4Kids 28
Retropharyngeal abscess
ACCT4Kids 29
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
ACCT4Kids 30
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
ACCT4Kids 31
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
ACCT4Kids 32
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
ACCT4Kids 33
Epiglottitis - lateral neck film
ACCT4Kids 34
Epiglottitis
ACCT4Kids 35
Epiglottitis - etiology
Group A Streptococcus Other pathogens seen less frequently
include:Strep pneumoniaeHaemophilus parainfluenzaStaph aureus
ACCT4Kids 36
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
ACCT4Kids 37
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
ACCT4Kids 38
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
ACCT4Kids 39
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
ACCT4Kids 40
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
ACCT4Kids 41
Foreign bodies
ACCT4Kids 42
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
ACCT4Kids 43
Reactive airway disease / Asthma
ACCT4Kids 44
RAD / Asthma - children <3 years - small intrapulmonary airways Poor collateral ventilation Decreased elastic recoil pressure Partially developed diaphragm
ACCT4Kids 45
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
ACCT4Kids 46
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
ACCT4Kids 47
Bronchiolitis
ACCT4Kids 48
Bronchiolitis - symptoms
Apnea, bradycardia Desaturations Cough, copious secretions Tachypnea, tachycardia Crackles, wheezing Increased WOB, retractions Flaring, grunting Pallor, cyanosis
ACCT4Kids 49
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
ACCT4Kids 50
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
ACCT4Kids 51
Pneumonia Types:
Bronchopneumonia - lobar consolidation
Interstitial - usually viral More common in infants & toddlers
than in adolescents Commonly:
Viral, pneumococcus, MycoplasmaIn immunocompromised, anything is
possible!
ACCT4Kids 52
Pneumonia - symptoms
Cough Tachypnea Grunting Retractions Chest pain Vomiting, poor feeding, abdominal pain Fever depends on type
ACCT4Kids 53
Pneumonia
ACCT4Kids 54
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
ACCT4Kids 55
Pneumothorax
ACCT4Kids 56
Pneumothorax radiographs
ACCT4Kids 57
Tension PTX
NormalNormal
Tension PTXTension PTXPTXPTX
R L
heartheart
LungLung
HeartHeartAirleakAirleak
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