BJ Coopes, MD Medical Director, Pediatric Critical Care, Inpatient Pediatrics

Size: px

Start display at page:

Download "BJ Coopes, MD Medical Director, Pediatric Critical Care, Inpatient Pediatrics"

Morgan Wilkinson
6 years ago
Views:

1 BJ Coopes, MD Medical Director, Pediatric Critical Care, Inpatient Pediatrics

2 The BIG Question: Sick or Not Sick?

4 Signs of Respiratory Distress Tachypnea Tachycardia Retractions Accessory muscles Head bobbing Flaring Grunting Stridor Wheezing Prolonged expiration Sweating Inability to lie down Agitation Lethargy Cyanosis Apnea

5 Case # 1 4 yr, Homer Fever since am Quiet Doesn t feel good What do you want to know?

6 Epiglottitis No cough No wheeze No PO s Raspy voice this am No stridor (maybe last pm) Won t sleep Tripod Drooling Alert Aphonic HR 160, RR 14, Clear CRT 2 sec, PP +3 Temp o

Acute Epiglottitis Usually 2 5 years old High temp 102 105 o F Acute onset, with sore

7 Acute Epiglottitis Usually 2 5 years old High temp o F Acute onset, with sore throat, tripod position, drooling without cough Usually Hemophillus influenza B Strep pneumonia

8 RPA Epiglottitis

9 Epiglottitis

10 Epiglottitis airway Normal tch?feature=player_embedde d&v=kegh4nwiua4 Epiglottis tch?feature=player_embedde d&v=ec0vd795iag

11 Epiglottis

12 Epiglottitis

13 Epiglottitis Ceftriaxone (50 mg/kg/day IV/IM)

14 RPA 2 yr URI for 3 days Fever Malaise, listless Decr PO Decr UO What do you want to know?

15 Retropharyngeal Abscess Fever o x 3 days Froat hurt Hoarse voice Alert Sniffing Sits up, tripods HR 180, RR 20, CRT 3 s Adenopathy Erythematous Morbiliform rash

16 Retropharyngeal abscess

17 Retropharyngeal Abscess

18 RPA RETROPHARYNGEAL ABSCESS - YouTube.mht

19 RPA page&v=9f6tcigplk8

20 RPA Strep pneumo Staph aureus Oral flora Penetrating injury? Ceftriaxone (50 mg/kg/day IV/IM) Clindamycin(10 mg/kg q 8 h IV/PO) Vancomycin (10 20 mg/kg/day q 6 8h) Ampicillin sulbactam ( mg/kg/day q 6 12 h) Surgical treatment Intubation

21 RSV?

22 RSV vs pertussis page&v=lie_uelok3c

23 Croup

24 Croup

25 Croup Epiglottitis Tracheitis Incidence Common Rare Less common Age 0.5 3yr 2 7 yr yr Etiology Parainfluenza 1 Etc. Haemophilus (HIB) Onset of stridor Common, slow Very rapid, not common Rapid Fever Low grade High High Cough Common, seal Less common Common S aureus, S pneumo, M cat Voice Hoarse Muffled, none Very hoarse, hot Drooling No Yes No Preferred position Supine, cuddled Tripod Varies, sitting Breath sounds Good exchange, Slow, clear Wheezing, stridor noisy upper airway CXR Normal Varies Abnormal > 50% Neck Xray AP Steeple sign Normal Steeple sign Neck Xray Lat Endo findings Hazy subgl and soft tissue Nl supraglottic, edema airways Thumb print sign Erythema and edema supraglottis Hazy subgl and soft tissue Nl supraglottis, mucopurulent w ETT Response to epi neb Good none None / partial

26 Pertussis 4 mo, from Homer Cold, cough Decr PO Turned blue What do you want to know? Two RSV Patients - YouTube.website Two RSV Patients - YouTube.website

27 Pertussis = Whooping Cough Usually children < 4 y.o. Who have not been immunized Infants have high mortality rates Cough not always present Whoop (insp stridor) seldom present Bradycardia can be independent of cough / apnea CPR Infectious! dtap Mask on patient Macrolide decr carrier state to 5 days. EES Azithromycin Supportive Rx does not always work. ECMO

28 Pertussis 6 month old baby with Whooping Cough - YouTube.website

29 Pertussis What Whooping Cough Sounds Like. - YouTube.website

30 Pertussis whooping cough in 7 week old baby - YouTube.website Clinical presentation of Whooping Cough - YouTube.website

32 FBA 16 mo Wheezing Decr BS right base Hyperexpanded right lung Wheezing on right only T 102 o Worsens after albuterol

33 Cricoid cartilage prevents Enface presentation Foreign Body

34 FBA

35 Foreign Body Choking Coughing Decreased breath sounds Tachypnea Swelling Allergy Anaphyllaxis

36 Site of Lodging of Foreign Body Right Main Bronchus Shivakumar AM, Naik AS, Shetty KD, Praveen DS. Indian J Pediatr Sep;71(9):

37 Foreign Body in Lungs Nuts, raw carrots, and popcorn kernels (64%). Morley RE, Ludemann JP, Moxham JP, Kozak FK, Riding KH. J Otolaryngol Feb;33(1): Hot dogs, bread, grapes Most common FB killer Witnessed aspiration 33 89% Lack of history unreliable as exclusionary Age is highest risk factor < 18 mo up to 4 yr Pre teens Infants with 3 yo sibs

38 Radiology in Foreign Body CXR can be helpful, BUT. Radio opaque foreign bodies (FBs) in 1/5 of all patients with FBA. Local hyperexpansion Pneumonia Atelectasis

39 Complications of FBA respiratory distress, asphyxia, cardiac arrest, fever, laryngeal edema, pneumothorax, anaphylaxis hemoptysis, Pneumonia, Bronchiectasis Atelectasis, bronchial stricture

40 Clove that was coughed out

41 Child after coughing out clove

42 2 yo Temp 105 o Decr PO Decr UO Listless Tachypneaic Grunting Unresponsive to phlebotomy Decr BS on left

43 Empyema US, CT scan

44 Empyema Pigtail catheter Chest Tube Video Assisted Thorascopy Thoracotomy Pleurodysis Lobectomy?? S. pneumo M. cat H. flu type A Z S. aureus Vancomycin Ceftriaxone

45 8 mo Yupik Male Temp 105o

49 Mononucleosis

51 Strep vs Mono

52 Strep vs Mono

53 Mononucleosis Malaise, lethargy, somnolence Aches / pains Anorexia Fever Sore throat, hoarseness Throat culture negative Monospot + Decadron

54 Mononucleosis Vomiting Pallor Somnolence No urine output today Brown last pm HR 108 BP 90/65 SpO2 100% RA CRT hard to measure MD called when labs return Code Blue. Unable to ventilate after intubation

55 Mononucleosis

56 Mono CBC with MANUAL diff CXR Electrolytes if dehydrated Urinalysis Monospot if >6 yr EBV PCR EBV IgM

57 9 mo, Russian 1 mo URI sx, rash Rash resolved spont 9 days PTA,? Pna Given unknown abx 6 day PTA, still pna sx Given Ceftriaxone x 2 d 5 day PTA, Admitted Incr T, emesis Somnolence Lack of interest in crawling, playing CSF: 341 WBC, 10 RBC, glu 10, Prot 134 IV Ceftriaxone

61 Tuberculosis Common in Alaska Increases with foreign immigration Fever, malaise, anorexia, wt. Loss or specific sx lung, brain, kidney

62 STridor Inspiratory stridor at rest - severe croup - YouTube.website

63 Stridor in Infant Stridor & Respiratory Distress in an Infant - YouTube.website

64 Croup baby with Croup Stridor Barking Cough visual & audio sound - YouTube.website

65 Laryngomalacia Laryngomalacia - YouTube.website Aiden - tracheomalacia - YouTube.website

66 Presentation:

Objectives. Case Presentation. Respiratory Emergencies

Objectives. Case Presentation. Respiratory Emergencies Respiratory Emergencies Objectives Describe how to assess airway and breathing, including interpreting information from the PAT and ABCDEs. Differentiate between respiratory distress, respiratory failure,