Critical Concepts:

Critical Concepts: Shock Inadequate peripheral perfusion where oxygen delivery does not meet metabolic demand  Adult vs Pediatric Shock - Same causes/different frequencies  Pediatric Shock  Hypovolemia  Most common cause of pediatric shock  Small blood volumes (80cc/kg)  Sepsis  Second most common cause of pediatric shock  Immature immune system Pediatric Shock  Cardiogenic  Primary pump failure – congenital heart disease  Secondary failure from: ○ Hypoxia ○ Acidosis ○ Hypoglycemia ○ Hypothermia ○ Drug toxicity Pediatric Shock  Neurogenic  Rare  Low incidence associated with low pediatric spinal cord trauma rates Pediatric Shock Early shock - Very difficult to detect  Pediatric cardiovascular system compensates well   Early Signs/Symptoms     Tachycardia - carry chart of normals Slow capillary refill ( > 2 seconds) Pale or mottled skin, cool extremities Tachypnea Pediatric Shock  Late Signs/Symptoms  Weak or absent peripheral pulses  Decreasing level of consciousness  Hypotension  Hypotension = Pre-arrest State Pediatric Shock Management Initial assessment may detect shock, but not its cause  When in doubt, treat for hypovolemia  Shock Management  Airway  Open, clear, maintain  Non-invasive (chin lift, jaw thrust)  Invasive (endotracheal intubation)  Trauma patient - ? C-spine injury Shock Management  Breathing  100% oxygen indicated for all shock  Ventilation ○ Reduce work of breathing ○ Do not “fight” patient Shock Management  Circulation  Apply cardiac monitor  Control obvious hemorrhage  Elevate lower extremities Shock Management  Fluid Resuscitation  Obtain Access quickly  Consider intraosseous access  Fluid bolus: 20 ml/kg isotonic fluid  Most common error--Too LITTLE fluid  Reassess for: ○ Improved perfusion ○ Respiratory distress  Check blood glucose ○ Give D25W if D-stick < 40 - 60 Disorders of Hydration  Causes  Vomiting  Diarrhea  Fever  Poor oral intake  Diabetes mellitus Disorders of Hydration  Mild dehydration ( <5% weight loss)  Mild increased thirst  Slight mucous membrane dryness  Slight decrease in urinary frequency  Slight increase in pulse rate Disorders of Hydration  Moderate dehydration (5 - 10% weight loss)  Moderate increase in thirst  Very dry, “beefy red” mucous     membranes Decrease in skin turgor Tachycardia Oliguria, concentrated urine Sunken eyes Disorders of Hydration  Severe dehydration - 15% weight loss)         Severe thirst Tenting of skin No tears when crying Weak, thready pulses Marked tachycardia Sunken fontanelle Hypotension Decrease in LOC (10 Disorders of Hydration  Management  Oxygen  20 cc/kg boluses LR  Repeat boluses as needed to ○ Restore peripheral pulses ○ Decrease tachycardia ○ Improve LOC Remember that hypotension is a late and ominous finding!  Reassess frequently  Normal upper airway anatomy Tonsils Epiglottis Esophagus Tongue Trachea Larynx ACCT4Kids 18 Typical causes of distress  Upper airway      Croup Retropharyngeal abscess Epiglottitis Foreign body aspiration Lower airway     ACCT4Kids Reactive airway disease / asthma Bronchiolitis Pneumonia Pneumothorax 19 Why are kids different?     Obligate nosebreathers Tongue relatively larger Higher larynx (C3-C4 versus C6) Narrowing of airway causes exponential rise of airway resistance ACCT4Kids    Less elasticity of alveoli Lower FRC Diaphragm  Flatter  Muscle fibers more vulnerable to fatigue  Chest wall  More compliant  Ribs more horizontal 20 Signs & symptoms of distress         Nasal flaring Hypoventilation, apnea Stridor Grunting Wheezing Pallor, ashen color  WOB Tachypnea ACCT4Kids         21 Cyanosis Head bobbing Tripod positioning Retractions  Level of consciousness  Air movement Acidosis Hypercapnea Croup (LaryngoTracheoBronchitis)     Most severe in kids 6 mo - 3 years old Males Winter months Associated illnesses  Ear infection  Pneumonia  Organisms: parainfluenza types 1, 2 & 3, adenovirus, RSV, influenza ACCT4Kids 22 Croup symptoms        ACCT4Kids 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 23 Croup diagnosis Clinical diagnosis  Does not require neck X-ray  Steeple sign  Consider X-ray in patients with atypical presentation or clinical course  ACCT4Kids “Steeple sign” 24 Croup treatment Position of comfort, with parent  Dexamethasone 0.6 mg/kg IV/IM Hypopharnyx  Epi neb  Heliox Narrow air column  SQ Epi Trachea  Cool mist  Steeple sign ACCT4Kids 25 Retropharyngeal abscess    Deep, potential, space of the neck Children age 6 months to 6 years Other deep neck abscesses more frequent in older children & adults  Parapharyngeal  Peritonsillar   ACCT4Kids Potential for airway compromise Complications secondary to mass effect, rupture of the abscess, or spread of infection 26 Retropharyngeal abscess symptoms        Fever, chills, malaise Decreased appetite Irritability Sore throat Difficulty or pain swallowing Jaw stiffness Neck stiffness ACCT4Kids     27 Muffled voice “Lump” in the throat Pain in the back & shoulders upon swallowing Difficulty breathing is an ominous complaint that signifies impending airway obstruction Retropharyngeal abscess ACCT4Kids 28 Retropharyngeal abscess  Polymicrobial infection typical  Gram-positive organisms and anaerobes predominating  Gram-negative bacteria possible  Oropharyngeal flora  Most common cause is group A betahemolytic streptococci ACCT4Kids 29 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 30 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 31 Epiglottitis - signs & symptoms More acute presentation in young children than in adolescents or adults  Symptoms for <24 hrs   High fever, severe sore throat, tachycardia, systemic toxicity, drooling, tripod position  ACCT4Kids Moderate or severe respiratory distress with inspiratory stridor & retractions 32 Epiglottitis - lateral neck film ACCT4Kids 33 Epiglottitis ACCT4Kids 34 Epiglottitis - etiology Group A Streptococcus  Other pathogens seen less frequently include:   Strep pneumoniae  Haemophilus parainfluenza  Staph aureus ACCT4Kids 35 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 36 Foreign body (FB) aspiration  Toddler through preschool age common  No molar teeth for thorough chewing  Talking, laughing, and running while eating Nuts, raisins, sunflower seeds, pieces of meat and small smooth (grapes, hot dogs, & sausages)  Dried foods absorb water  ACCT4Kids 37 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 cords  Mainstem bronchi  Trachea  Lobar bronchi ACCT4Kids 38 Foreign Body aspiration  Extrathoracic FB:  Breath sounds are inspiratory  Intrathoracic FB  Noises are symmetric but more prominent in central airways  If FB is beyond the carina, the breath sounds are usually asymmetric ○ 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 39 Foreign Body aspiration  Hyperinflation & air-trapping of the affected lobe(s) is typical  Best seen with X-ray taken at expiration  Difficult in little kids  ACCT4Kids May see soft tissue opacity in proximal airway 40 Foreign bodies ACCT4Kids 41 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 42 Reactive airway disease / Asthma ACCT4Kids 43 RAD / Asthma - children     <3 years - small intrapulmonary airways Poor collateral ventilation Decreased elastic recoil pressure Partially developed diaphragm ACCT4Kids 44 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 45 Bronchiolitis  Organisms: RSV most common  Others: parainfluenza, influenza, human metapneumovirus (hMPV), adenovirus, mycoplasma      ACCT4Kids 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 46 Bronchiolitis ACCT4Kids 47 Bronchiolitis - symptoms Apnea, bradycardia  Desaturations  Cough, copious secretions  Tachypnea, tachycardia  Crackles, wheezing  Increased WOB, retractions  Flaring, grunting  Pallor, cyanosis  ACCT4Kids 48 Bronchiolitis - diagnosis  No diagnostic tests needed, but possibly:  Rapid viral panel (antigen or FA panel)  Viral cultures  CXR - hyperinflation, peribronchial cuffing, patchy atelectasis   Tachypnea, WOB, wheezing Hx URI  fever, cough, runny nose, appetite   ACCT4Kids Apnea (may occur w/o other symptoms) May be complicated by secondary bacterial infection 49 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 50 Pneumonia  Types:  Bronchopneumonia - lobar consolidation  Interstitial - usually viral  More common in infants & toddlers than in adolescents  Commonly:  Viral, pneumococcus, Mycoplasma  In immunocompromised, anything is possible! ACCT4Kids 51 Pneumonia - symptoms Cough  Tachypnea  Grunting  Retractions  Chest pain  Vomiting, poor feeding, abdominal pain  Fever depends on type  ACCT4Kids 52 Pneumonia ACCT4Kids 53 Pneumonia – Initial Treatment O2, keep sats ≥92%  CPAP, BiPAP  Antibiotics, if considered bacterial   Cefotaxime + vancomycin  Azithromycin Monitor mental status  Intubate & ventilate if respiratory failure  Complications: effusion, abscess  ACCT4Kids 54 Pneumothorax ACCT4Kids 55 Pneumothorax radiographs ACCT4Kids 56 Tension PTX Normal Lung Heart Airleak R L heart PTX ACCT4Kids Tension PTX 57

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