Transcript SAED Recert - Hamilton Health Sciences

CROUP
Prepared by:
South West Education
Committee
Croup Protocol
South West Education Committee
OBJECTIVES
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Identify the anatomical differences in
pediatrics which impact croup patients.
Review of pediatric assessment
Identify common presentations for
croup.
Distinguish croup from Epliglottitis.
Describe the treatment for croup.
Explain the indications for treatment.
ANATOMICAL DIFFERENCES
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Anatomy is smaller
and proportioned
differently.
Head
proportionately
larger on a weak
neck.
Obligatory nose
breathers. (Infants)
AIRWAY - Pediatric vs. Adult
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Narrower at all levels
The mandible is
proportionally smaller
in young children
The tongue is
proportionally larger
than adults
Larynx is more
anterior and superior
than an adults’ (C3C4)
AIRWAY - Pediatric vs. Adult
AIRWAY
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Cricoid ring is the
narrowest part of the
airway in young
children
Tracheal cartilage is
softer
Trachea is smaller in
both length and
diameter
A Picture is Worth…..
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Small, hypotonic jaw, large tongue, tonsils,
adenoids, arytenoids, uvula, long floppy
epiglottis. (prone to swelling)
Excessive secretions. (requires suctioning)
Gums are more delicate, bleed easily, softer
teeth which dislodge easily
Anatomical Differences
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Why is this
difficult?
The larynx:
– 3-3-2
– More anterior.
– More superior.
thyromental
distance
– Big teeth or no
teeth.
– Cone shaped.
AIRWAY
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BLS first
– Open & maintain a/w
– Ensure patency
• Suction & insert oral &/or
nasal a/w
– ORAL or NASAL ETT?
– Assist/prep for intubation
HUMAN ERROR
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Most preventable deaths that happen in
the pre-hospital care setting are STILL
attributed to poor airway management
practices.
It has been found that upwards of 86%
of preventable deaths of inhospital
patients with airway complications were
attributed to human error.
PEDIATRIC REVIEW
CHEST AND LUNGS
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Ribs are positioned horizontally
Ribs are more pliable and offer less
protection to organs
Chest muscles are immature and fatigue
easily
Lung tissue is more fragile
Mediastinum is more mobile
Thin chest wall allows for easily transmitted
breath sounds
PEDIATRIC REVIEW
ABDOMEN
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Immature abdominal muscles offer less
protection
Abdominal organs are closer together
Liver and spleen are proportionally
larger and more vascular
PEDIATRIC REVIEW
RESPIRATORY SYSTEM
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Tidal volume is proportionally smaller to
that of adolescents and adults
Metabolic oxygen requirements of
infants and children are about double
those of adolescents and adults
Children have proportionally smaller
functional residual capacity, and
therefore proportionally smaller oxygen
reserves
PEDIATRIC REVIEW
CARDIOVASCULAR SYSTEM
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Cardiac output is rate dependent in infants
and small children
Vigorous but limited cardiovascular reserve
Bradycardia is a response to hypoxia
Children can maintain blood pressure longer
than adults
Circulating blood volume is proportionally
larger than adults
Absolute blood volume is smaller than adults
WRAP UP!
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Smaller chest and respiratory reserve, belly
breathers.
Poorly developed accessory and abdominal
muscles. ( prone to fatigue / injury)
Poorly developed rib cage. (prone injury)
Excessive air swallowing. (large stomach)
Poor gastric emptying. (vomit)
Immature temperature regulatory system.
Higher metabolic rate requires a higher
respiratory and circulatory rate. Conversely they
have a much lower blood pressure due to the lack
of plaque, arteriosclerosis and muscle
development in arteries.
ASSESSMENT PEDIATRICS
SCENE ASSESSMENT
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Observe the scene for hazards or potential
hazards
Observe the scene for mechanism of
injury/illness
– Ingestion
• Pills, medicine bottles, household chemicals,
etc.
– Child abuse
• Injury and history do not coincide, bruises not
where they should be for mechanism of injury,
etc.
– Position patient found
INITIAL ASSESSMENT
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General impression
– General impression of environment
– General impression of parent/guardian and
child interaction
– General impression of the patient/pediatric
assessment triangle
• A structure for assessing the pediatric
patient
• Focuses on the most valuable
information for pediatric patients
• Used to ascertain if any life-threatening
condition exists
• Components
GCS / LOA
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Determine level of consciousness
– AVPU scale
• Alert
• Responds to verbal stimuli
• Responds to painful stimuli
• Unresponsive
– Modified Glasgow Coma Scale
– Signs of inadequate oxygenation
Pediatric Glasgow Coma Scale
0-1 year old
>1 year old
Score
Eye Opening
Spontaneous
To shout
To pain
No response
spontaneous
To command
To pain
No response
4
3
2
1
Verbal
Cry, smiles, coos
Cries
Inappropriate cry
Grunts
No response
Appropriate words
Disorientated
Cries/screams or inappropriate
Grunts or incomprehensible
No response
5
4
3
2
1
Localizes pain
Withdraws
Flexion
Extension
None
Obeys Command
Localizes pain
Withdraws
Flexion
Extension
None
6
5
4
3
2
1
Motor
AIRWAY AND BREATHING
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Airway – determine patency
Breathing should proceed with adequate
chest rise and fall. Visualize/Expose chest.
Signs of respiratory distress
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Tachypnea
Use of accessory muscles
Nasal flaring
Grunting
Bradypnea
Irregular breathing pattern
Head bobbing
Absent breath sounds
Abnormal breath sounds
CIRCULATION
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Pulse
– Central
– Peripheral
– Quality of pulse
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Blood pressure
– 2 x Age + 80 = systolic
– 2/3 the systolic = diastolic
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Skin color
Active hemorrhage
TRANSITION PHASE
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Used to allow the infant or child to
become familiar with you and your
equipment
Use depends on the seriousness of the
patient's condition
– For the conscious, non-acutely ill child
– For the unconscious, acutely ill child do not
perform the transition phase but proceed
directly to treatment and transport
APPROACH TO PEDIATRICS
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Always remember there are 2 patients.
Stay CALM, reassure parents and child.
– remain calm but be attentive and willing to act
aggressively to reduce morbidity and mortality.
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Handle child gently & explain before doing.
Try to examine small children on parents lap when
appropriate.
If child or parents are extremis to the point they
endanger resuscitation efforts, separate.
Prevent heat stress and preserve Child’s body
heat.
PATIENT COMMUNICATION
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Try to never be alone with a pediatric
patient.
Sit close, eye level, but do not overcrowd.
Use toys to aid your exam.
Demonstrate on parents.
Offer rewards.
Be direct, do not lie!!!!!!!
Parents sometimes feel guilty even if they
did nothing wrong.
HISTORY TAKING
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Parents of chronically ill children know the
disease better than most care givers - ask them.
Ask if child has had a fever / are they hot.
Hx of laboured breathing or excessive drooling.
Lethargy. (A very quiet child is a scary thing)
Blank staring, twitching other bizarre behavior.
Poor appetite, refusal to eat, vomiting or diarrhea
recently.
Increase or decrease in wet diapers.
Inconsolable crying / screaming does not
recognize parents.
FOCUSED HISTORY–
CONTENT
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Chief complaint
– Nature of
illness/injury
– How long has the
patient been
sick/injured
– Presence of fever
– Effects on behavior
– Bowel/urine habits
– Vomiting/diarrhea
– Frequency of
urination
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Past medical history
– Infant or child under
the care of a
physician
– Chronic illnesses
– Medications
– Allergies
DETAILED PHYSICAL
EXAMINATION
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Should proceed from head-to-toe in older children
Should proceed from toe-to-head in younger
children (less than 2 years of age)
Depending on the patient’s condition, some or all
of the following assessments may be appropriate:
– Pupils
– Capillary refill
– ECG monitoring
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Is patient hypoglycemic?
- Hydration
- Pulse oximetry
ON-GOING ASSESSMENT
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Appropriate for all patients
Should be continued throughout the patient care
encounter
Purpose is to monitor the patient for changes in:
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Respiratory effort
Skin color and temperature
Mental status
Vital signs (including pulse oximetry measurements)
Measurement tools should be appropriate for size
of child
RESPIRATORY
COMPROMISE
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Several conditions manifest chiefly as respiratory
distress in children including:
– Upper and lower foreign body airway obstruction
– Upper airway disease (croup, bacterial tracheitis, and
epiglottitis)
– Lower airway disease (asthma, bronchiolitis, and
pneumonia)
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Most cardiac arrests in children are secondary to
respiratory insufficiency thus, respiratory
emergencies require rapid prehospital
assessment and management
CROUP
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Laryngotracheobronchitis
Common inflammatory respiratory illness
in children
– Viral infection of the upper airway
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Differentiation between croup and
epiglottitis in the prehospital setting may
be difficult
Upper Respiratory Distress
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CROUP
– upper airway infection with “barking” cough.
– mild to moderate respiratory distress with predominant
stridor.
– may be relieved by cold air. (mist)
– usually 2 - 7 years of age, Rapid onset.
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Epiglottitis DEADLY EMERGENCY!!!!!
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Rarely have Stridor. (inspiratory when they do)
Excessive drooling.
Absence of a “barking seal cough.”.
Preference for sitting in “sniffing position.”
Very “eerie”, quiet & obtunded look.
High grade fever.
Upper Respiratory Distress
PRESENTATION
Onset
Fever
Sore Throat
Fear, Anxiety
Pale/Cyanosis
Drooling
Cough
Stridor
Voice
Pref. Position
CROUP
EPIGLOTTITIS
Sudden
Gradual
Slight/absent
High
Variable
Prominent
Variable
Prominent
Variable
Usually
Not usual
YES
“Barking”
No Barking cough
Inspiration
Rare
Very hoarse
Muffled
Variable
“Sniffing position”
CROUP PROTOCOL
INDICATIONS
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Any patient who is
<8 years old .
A current Hx of upper
respiratory infection.
Barking cough
(seal-like)
Stridor at rest and/or
Altered level of
consciousness and/or
Cyanosis.
PROCEDURE
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Monitor heart rate
Attach cardiac
monitor
Assess pulse rate.
Pulse rate must be
<200 bpm.
PROCEDURE
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Nebulized
Epinephrine will
not exceed 2
doses.
WHY EPINEPHRINE?
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Epi. acts on the subglottic swollen area
to vasoconstrict blood vessels and
reduce the swelling with the alpha 1
effects.
Salbutamol has no vasoconstrictive
effects and only acts on the smooth
muscles of the bronchioles with its beta
2 effects.
PROCEDURE
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Allow patient to
assume position of
comfort.
Reassure the
patient and parents.
Administer 100%
oxygen, via blow-by
if needed, while
preparing equipment
PROCEDURE
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Nebulize
Epinephrine
1:1000 based on
patients weight
and age.
EPINEPHRINE DOSING
Age and Weight
Dose
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<1y/o and <5kg
0.5 mg(0.5 ml) in 2 ml of
normal saline.
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<1y/o and >5kg
2.5 mg(2.5 ml) 2 ml of
normal saline may be
added.
>1y/o
and <8y/o
5.0 mg (5.0 ml)
REPEAT
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Repeat treatment
if no improvement
is observed.
Max Epinephrine
treatments is 2!
No exceptions.
TRANSPORT
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ALL PATIENTS
MUST BE
TRANSPORTED
WITHOUT DELAY.
REASSESS - ENROUTE
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Reassess every 5
minutes.
Airway
Breathing
Circulation
Vitals
And document it all.
QUESTIONS?