Pediatric Respiratory Emergencies

Foreign Body Aspiration

Patient In Severe Respiratory Distress

  • Alternate between 5 back blows and 5 chest thrust in infants
  • In school-aged kids perform Heimlich
  • If the patient becomes apneic/unconscious, perform laryngoscopy and attempt removal of the foreign body if visible

Surgical Airway in Children

Croup

Overview

  • Harsh barky cough with URI symptoms and stridor
  • Most common in winter months

Severity

Symptoms

Mild Stridor with agitation
Moderate Stridor at rest
Severe Severe stridor with respiratory distress

The Forgotten Diagnoses

Consider an alternative diagnosis in patients unresponsive to standard treatment for croup.

  1. Bacterial Tracheitis
  2. Foreign body aspiration
  3. Retropharyngeal abscess
  4. Epiglottitis

Treatment

  • All patients get dexamethasone 0.6 mg/kg IV or PO (IV formulation is also given PO)
  • Nebulized budesonide 2mg/2mL can be given as an alternative to dexamethasone
  • Patients with moderate to severe croup should be given 0.5 mL racemic epinephrine 2.25 %

In patients with clinical improvement after racemic epinephrine observe for 4 hours before discharge.

Bronchiolitis

Overview 

  • URI symptoms with ronchi, wheezing, or crackles on physical exam
  • Most common in patients less than 2 (wheezing is more consistent with bronchiolitis and not asthma in this age group)
  • Clinical diagnosis
  • Common from November to March

Treatment

  • Nasal suctioning
  • Oxygen therapy for patients with oxygen saturation less than 90%
  • Consider albuterol and/or dexamethasone PLUS racemic epinephrine in ill-appearing patients if other treatments have failed (limited evidence)

ASTHMA

Overview

  • Obstructive lung disease leading to bronchoconstriction and inflammation.

The Forgotten Diagnoses

The below diagnoses can be easily be overlooked.

  1. Anaphylaxis
  2. Foreign body aspiration leading to obstruction of lower airways

Treatment

Treatment Dose
Bronchodilators Give 0.5 mg/kg albuterol (2.5mg/3 mL). Most children can tolerate 15 mg. Albuterol is well tolerated and dosing does not have to be precise. Ipratropium 250 mcg in children less than 20 kg and 500 mcg in children greater than 20 kg. Total of 3 doses of ipratropium can be given
Steroids Sick: Methylprednisolone 1 mg/kg IV
Not Sick: Prednisolone 1mg/kg PO
Magnesium 50 mg/kg IV
Epinephrine Less than 30 kg = Infants give 0.15mg IM
Greater than 30 kg = School age give 0.3mg IM, ok to use approximate dosing for rapid resuscitation of sick asthmatics

Noninvasive ventilation

Despite medical therapy, children with severe respiratory distress may require respiratory support. In general continuous positive airway pressure improves oxygenation and  Bi-level positive pressure ventilation improves ventilation. For more details on noninvasive ventilation listen to the EMCRIT podcast.

Continuous positive airway pressure (CPAP) 

  • Start at 5 cm H2O and titrate to a max of 15 cm H2O

Bi-level positive airway pressure (BPAP)

  • Expiratory positive airway pressure (EPAP) starting at 5 cm H2O with a max of 15 cm H2O
  • Inspiratory positive airway pressure (IPAP) starting at 10 cm H2O with a max of 15 cm H2O

Emergency Medicine FOAM PoDCASTS

Breathe! Approach to the child who is short of breath. St.Emlyn’s

Episode 46.0 – Grand Rounds (Ilene Claudius) – Pediatric SOB

References 

  1. Shefrin A, Busuttil A, Zemek R. Wheezing in infants and children. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2016:(Ch) 124.
  2. Mapelli E, Sabhaney V. Stridor and drooling in infants and children. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2016:(Ch) 123.
  3. Nagler J, Cheifetz I. Noninvasive ventilation for acute and impending respiratory failure in children. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc.

 

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