Objectives. Case Presentation. Respiratory Emergencies

Transcription

1 Respiratory Emergencies Objectives Describe how to assess airway and breathing, including interpreting information from the PAT and ABCDEs. Differentiate between respiratory distress, respiratory failure, and respiratory arrest based on history, physical exam, and physiologic monitoring. Contrast the key signs and symptoms of upper airway obstruction versus lower airway obstruction. Discuss possible complications of assisted ventilation, and outline strategies to identify and correct these complications. Case Presentation A 10-month-old girl with rapid breathing and stridor The mother states that the child has had a cold and fever for 2 days. She developed a loud cough, wheezing, and difficulty breathing earlier today. She has no history of foreign body ingestion or aspiration. 1

2 General Impression: PAT Appearance Sleepy, but responds to parent Work of breathing Audible stridor at rest; intercostal and subcostal retractions; no obvious drooling Circulation to Skin Pale What is your general impression? General Impression General impression: Sick Respiratory distress Physiologic problem: Upper airway obstruction Primary Assessment: ABCDEs Airway stridor Breathing RR 56; inspiratory stridor at rest, decreased breath sounds; SpO 2 95% on blow-by oxygen Circulation HR 160; pulse strong and regular; BP 90/70 Disability alert Exposure no signs of injury 2

3 Management Priorities Respiratory distress from upper airway obstruction probable croup. ABCDEs confirm that the infant is seriously ill. Management: Leave in a position of comfort. BLS: Give supplemental oxygen. ALS: Give nebulized epinephrine on scene. Transport: Stay or go? Key Concept: Causes of Upper Airway Obstruction Croup Epiglottitis Foreign body aspiration Anaphylaxis Congenital disorders Trauma Other infections: retropharyngeal abscess, peritonsillar abscess Key Concept: Croup Viral disease resulting in inflammation, edema, and narrowing of larynx or trachea Most common upper airway disease 1.5 cases/100 children <6 years of age Usually affects infants and toddlers Seasonal late fall and early winter 3

4 Key Concept: Pathophysiology of Croup Virus transmitted through respiratory secretions Inflammation of trachea, larynx, and bronchi Vocal cord and subglottic edema Key Concept: Signs and Symptoms of Croup Cold symptoms for 1 3 days All symptoms last about 4 7 days Nasal congestion and hoarseness Barking or seal-like cough (94%) Stridor (58%) Various levels of respiratory distress Tachypnea Low-grade fever Key Concept: Croup For each 1 mm of edema 50% reduction in cross-sectional area of trachea 4

5 Key Concept: Signs of Respiratory Failure With Croup Agitation Lethargy Hypoxia/cyanosis Marked decrease in tidal volume Apnea Management Priorities Alert respiratory distress Position of comfort Supplemental oxygen/cool mist? Nebulized epinephrine Not alert respiratory failure Bag-mask ventilation ETI if apneic Key Concept: Nebulized Epinephrine Symptomatic treatment for patients with stridor at rest, hypoxia, severe respiratory distress Mechanism of action: Decreases subglottic edema through vasoconstriction 5

6 Key Concept: Epinephrine Dose Racemic epinephrine 2.25% solution 0.1 ml/kg by inhalation in 3 ml normal saline (0.5 ml maximum) L-epinephrine (1:1,000) ml/kg by inhalation in 3 ml normal saline (5 ml maximum) Case Progression En route: Patient receives oxygen and nebulized epinephrine. ED course: Patient is given a corticosteroid orally. Discharged home after 4 hours of observation with marked improvement in symptoms. Case Summary Croup is the most common cause of upper airway obstruction in children. Treatment is largely supportive. Nebulized epinephrine provides rapid symptomatic relief in children with stridor at rest and increased work of breathing. 6

7 Case Presentation You are called to a residence for an 11-year-old girl who is having difficulty breathing. Prearrival Preparation Review the causes of respiratory distress in schoolaged children. Asthma Pneumonia Foreign body aspiration Anaphylaxis Chest trauma Review team roles and possible management (airway equipment, medication doses). Scene Size-Up You are first on scene to a home where you are waved into the living room by an anxious mother. The father is attending to the 11- year-old girl, who is obviously working hard to breathe. 7

8 General Impression: PAT Appearance Anxious, alert, able to respond to questions with only single words Circulation to skin Pale, lips slightly blue What is your general impression? Work of Breathing Seated, leaning forward on outstretched arms; marked retractions and nasal flaring; audible wheeze General Impression General impression: Sick Respiratory distress Physiologic problem: Lower airway obstruction Primary Assessment: ABCDEs Airway patent, no stridor Breathing RR 48; poor air entry; diffuse wheezing; SpO 2 86% Circulation HR 130; radial pulse full; capillary refill <2 seconds; nail beds blue; BP 98/68 Disability AVPU alert Exposure no signs of trauma or rash 8

9 Management Priorities Immediate treatment: Leave child in a position of comfort. BLS: Oxygen 15 L by mask and assist patient with albuterol MDI if local protocol allows. ALS: Nebulized albuterol 2.5 mg every 20 minutes for 3 doses. Repeat albuterol as necessary. Consider ipratropium (<12 years 0.25 mg; if >12 years 0.5 mg) and IM epinephrine. Stay or go? Give first albuterol treatment on scene and then continue en route. History Taking: SAMPLE Signs/symptoms: Cold symptoms for 2 days Allergies: penicillin, nuts Medications: Fluticasone inhaler once a day; albuterol inhaler as needed last dose 1 hr ago Past medical problems: Asthma; anaphylaxis to nuts Last meal: Snack 3 hours ago Events leading to illness/injury: Wheezing started after soccer practice. Key Concept: Asthma Asthma is the most common chronic disease of childhood. Five million children in the United States have the disease. Death from asthma is rising, and half of all pediatric deaths occur in the prehospital setting. 9

10 Key Concept: Factors That Suggest a More Severe Asthma Exacerbation A severe or fatal asthma attack is more likely if the child s history includes: Prior intensive care unit admissions or intubation More than three ED visits in a year More than two hospital admissions in the past year Use of more than one metered dose inhaler canister in the last month Use of steroids for asthma in the past Use of bronchodilators more frequently than every 4 hours Progressive symptoms despite aggressive home therapy Key Concept: Asthma Triggers Common triggers of an asthma attack include: Upper respiratory infection Exercise Exposure to cold air Emotional stress Passive exposure to smoke Key Concept: Asthma Pathophysiology and Clinical Signs Asthma is a disease of small airway inflammation. It leads to bronchoconstriction, mucosal edema, and increased secretions. Clinical signs and symptoms: Tachypnea Tachycardia Retractions Wheezing or decreased breath sounds Pulse oximetry may be normal or low 10

11 Key Concept: Signs of Severe Asthma Beware of the following features of the initial assessment, which suggest severe bronchospasm and respiratory failure: Altered appearance Exhaustion Inability to recline Interrupted speech Severe retractions Decreased air movement Management Priorities Alert respiratory distress Position of comfort Supplemental oxygen Inhaled albuterol/ipratropium Not alert respiratory failure Bag-mask ventilation IM or SQ epinephrine ETI if apneic Case Progression En route: Patient received two 2.5 mg nebulized albuterol treatments. ED course: Patient received continuous nebulized albuterol and IV corticosteroids and was admitted to the Pediatric Intensive Care Unit. Diagnosis: Acute asthma exacerbation 11

12 Case Summary Asthma is the most common chronic disease of childhood. The severity of symptoms varies widely between individuals. Treat aggressively in children with a past history of severe attacks or signs of respiratory fatigue on exam. Inhaled beta-agonists and oxygen are the cornerstones of both field and hospital treatment. Summary Use the PAT and ABCDEs to assess the presence of respiratory distress versus failure and to identify airway obstruction. Management of respiratory distress from upper or lower airway obstruction begins with position of comfort and supplemental oxygen. 12