Emergency Medicine/Pediatric Airway Emergencies

Pediatric Upper Airway Emergencies

• Telluride EMS ==

Introduction

• Almost all pediatric “codes” are of respiratory origin ==

The majority of pediatric cardiopulmonary emergencies are caused by airway obstruction - this may be from a foreign object in the airway, swelling of the epiglottis (epiglotitis), croup (parainfluenza virus), or a peritonsillar abscess.

Anatomy

= Airway Anatomy

=

• Nose/Mouth ==
• Pharynx ==
• Epiglottis ==
• Trachea ==
• Cricoid Cartilage ==
• Bronchi ==
• Bronchus ==
• Lungs ==
• Diaphragm ==
• Alveoli ==

Children are different

• Narrow dimensions leave little margin for obstruction; infants: ==
• = 1mm glottic edema = 35% obstruction ===
• = 1mm subglottic edema = 44% narrowing ===
• Large epiglottis (nearly touches soft palate) and large tongue = nasal breathing ==
• = nasal obstruction can lead to significant resp. distress ===

Anatomy : Nose

• Nose is responsible for 50% of total airway resistance at all ages ==
• Infant: blockage of nose = respiratory distress ==

Anatomy : Tongue

• Large ==
• Loss of tone with sleep, sedation, CNS dysfunction ==
• Frequent cause of upper airway obstruction ==

Anatomy : Larynx

• High position ==
• = Infant : C 1 ===
• = 6 months: C 3 ===
• = Adult: C 5-6 ===
• Anterior position ==

Assessment: Look before taking hx Signs of Respiratory Distress

• Tachypnea ==
• Tachycardia ==
• Grunting ==
• Stridor ==
• Head bobbing ==
• Flaring ==
• Inability to lie down ==
• Agitation ==

Impending Respiratory Failure

• Reduced air entry ==
• Severe work ==
• Cyanosis despite O2 ==
• Irregular/shallow breathing or apnea ==
• Altered Consciousness ==
• Diaphoresis ==
• The above require immediate progression to laryngoscopy and intubation. ==

History

• Description of Onset ==
• = sudden or gradual? why? ===
• = Other symptoms? what? ===
• History of foreign body aspiration/ingestion ==
• Aggravating factors: feeding ==
• History of intubation ==
• = when? why? ===
• Birth history (syndromes, birth trauma) ==
• = vocal cord paralysis ===

Physical Exam

• Inspection ==
• Ascultation ==
• Repositioning ==

Physical Exam

• respiratory rate ==
• nasal flaring ==
• use of accessory muscles ==
• respiratory fatigue ==
• retractions ==
• STRIDOR ==
• = expiratory or inspiratory ===
• = what does a variation in stridor pattern indicate until proven otherwise? ===

Exam by obstruction

• nasal ==
• = nl voice or cry, nasal flaring, snorting ===
• oropharyngeal ==
• = nl voice (may be throaty), inspir, stridor, drooling, mouth open/jaw forward ===
• supraglottic ==
• = muffled/throaty voice (“hot potato”), inspir stridor, difficult feeding ===

Exam by obstruction

• glottic ==
• = hoarse or aphonic, biphasic stridor ===
• subglottic ==
• = biphasic stridor, nl feeding, barking cough ===
• tracheobronchial ==
• = expirat stridor or wheeze ===

Management

• More detailed lecture on pediatric airway management another time - Dr. Wheeler? ==
• Peds cardiopulmonary resusc (PALS) another time ==
• But quickly... ==

Intubation: Indications

• Failure to oxygenate ==
• Failure to remove CO2 ==
• Increased WOB ==
• Neuromuscular weakness ==
• CNS failure ==
• Cardiovascular failure ==
• *No LMA with airway obstruction ==

Intubation

• Pediatric Airway Emergencies... ==

< 6 mos. Congenital

• usually hx of weeks - months of Sx ==
• laryngomalacia ==
• = incr. w/ crying/URI/work of breathing ===
• = dec. w/ neck extension/prone ===
• = rarely - resp. distress failure to thrive, apnea, feeding problems ===
• vocal cord paralysis ==
• = h/o birth trauma, shoulder distocia, macrosomia, forceps delivery ===
• = difficult intubation - angle then turn; no force ===
• Arnold-Chiari malformation - neuro defs ==

Case # 1

• A 3-year-old previously healthy male was brought to the emergency room after a 1 day history of high fever. He has not been drinking as much as he usually does,and his parents relate that he has been becoming more restless over the past 2–3 hours. This is how he looks as you begin to evaluate him ==
• What do you notice/want to know? ==
• History ==
• = abrupt ===
• = high fever ===
• = sore throat ===
• = stridor ===
• = dysphagia ===
• = drooling ===
• Physical ==
• = toxic appearing ===
• = apprehensive ===
• = ashen-gray color ===
• = tripod positioning ===
• = neck slightly extended with chin forward “sniffing” ===
• = no cough ===
• = muffled voice ===

What’s the diagnosis?

• Epiglottitis ==
• Prior to H. Flu vaccination was in younger patient population (preschool age) ==
• now older kids with staph and strep bugs ==
• Life-threatening (up to 50% mortality) ==

Treatment

• DO NOT PLACE ANYTHING IN MOUTH: ==
• = laryngospasm ===
• Transport ==
• Do not jostle ==
• Position of comfort ==
• High flow humidified oxygen ==
• resp. fatigue, further obstruction, apnea ==
• = assist ventilation with BVM with secured pop-off valve --> inc. insp. pressures ===
• racemic epinephrine? ==
• In the ED... ==

Case #2

• A 16-month-old female is rushed to your emergency room after the terrified parents are awakened by stridorous breathing. ==
• Patient has had a few days of rhinorrhea, nasal congestion, and cough. ==
• Tonight the patient has a barking cough, biphasic stridor (insp > exp), intercostal retractions, and tachypnea. ==

What is the diagnosis?

• Croup - laryngotracheobronchitis ==
• How do you treat a mild case? ==
• humidified oxygen/ cold air ==
• If patient has stridor at rest or in resp distress? ==
• Racemic epinephrine - dec. edema (careful with LV obstruction) and ==
• dexamethasone .3 mg/kg PO (10 mg/ml IV sol) ==
• heliox - less dense than N2 to decrease airway resistance, but need 60-80% conc helium, so can’t have 40% O2 requirement ==
• Resting stridor, inc. PCO2, dec. PO2, AMS, cyanosis, < 1y --> resp. failure ==
• Consider elective intubation if: ==
• = 2 catech nebs in 1 hr + getting worse ===
• = hourly nebs beyond 2nd hr ===
• = AMS assoc. with resp distress ===
• = worsening despite tx ===
• = severe croup + neonatal lung disease ===
• = mod. to severe croup requiring transfer ===
• *use tube .5-1mm smaller to avoid subglottic stenosis ==

Case #3

• On scene you find a 3 year old male in play room with difficulty breathing in arms of frightened mother. ==
• “I was on the other side of the room with my back turned and I heard him suddenly wheezing.” ==
• The child is now standing next to you. You hear stridor. The child has shallow breathing with strong coughs occasionally, but is moving air. Child can whisper responses to your questions. ==
• What do you want to do? ==
• Encourage to cough and visualize oropharynx to see if you can remove FB. ==
• You are unable to visualize any FB and the child begins to have severe difficulty breathing, moving less air, but still maintaining airway. What do you want to do prior to transport? ==
• Laryngoscope and Intubate ==

• Before you get a chance to directly visualize the airway, the child loses his airway (cannot move air, cough, vocalize), but is still conscious. What do you want to do? ==
• Heimlich maneuver until obstruction relieved or unconscious ==
• And if this was an infant? ==
• 5 back blows/ 5 chest thrusts w/ head down until obstruction relieved or unconscious ==
• = to avoid injury to abdominal organs ===
• The child becomes unconscious. What do you want to do? ==
• Attempt ventilation ==
• if no airway management equipment - back blows/chest thrusts vs abd. thrusts ==
• between each cycle - visualize and remove visible FB *no blind sweeps - ventilate ==
• If you have airway management equipment - direct laryngoscopy, visualization, suction, removal of FB with McGill forceps, intubation if needed ==

Foreign Body Aspiration

• 1-3 yo peak - 90% < 4 yo ==
• toys & food ==
• = cylindrical or small, smooth, and round ===
• = peanuts, sunflower seeds, raisins, hot dogs, small sausages ===
• unilateral wheezing on auscultation if distal ==

Other Ped. Airway Emergencies

• Bacterial Tracheitis ==
• Retropharyngeal Abscess ==
• Peritonsillar Abscess ==
• etc. ==