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Public Access Bleeding Control Station
The North American Rescue (NAR) Public Access Bleeding Control Station provides bystanders and initial first responders with quick and easy access to essential medical equipment to stop life-threatening bleeding in public buildings and populated public areas.
R-CAT Window for STEMI
This pocket size, flexible card contains a reversible baseline window that can be used on an actual patient’s 12 lead EKG to identify patterns of ischemia, injury and infarction.
Curaplex Glucose Start Kit
The Curaplex® Glucose Start kit allows you to have the ease and convenience of having a ready-to-use set of products for checking glucose levels at your disposal.
January 1, 2012
Pediatric respiratory distress
Truth be told, I get nervous with sick kids. My perception of their fragility and the stress of the anxious parents shakes my confidence a bit each time I am in those situations. Of these events, perhaps pediatric respiratory distress generates the most amounts of the nerves, mostly because I know how the stability of the child is very dependent on his ability to adequately ventilate.
With winter setting in, a review of pediatric respiratory emergencies can help refresh our fundamental knowledge base on these calls.
Basic Anatomy and Physiology
Pediatric patients primarily breathe using their diaphragms; there is limited ability to use the intercostal muscles and other accessory muscles during periods of respiratory distress. A child can fatigue quickly and drop into respiratory failure with little warning.
The pediatric laryngeal opening is more anterior and cephalad compared to adults. This can make advanced airway procedures more challenging to ALS providers. Moreover, the diameter of the airway narrows very quickly in the cricoid area. Along with a shorter tracheal length, the chances of dislodging an endotracheal tube or intubating the right mainstem bronchus are greater in a pediatric patient.
Like adults, children depend on their ability to exchange oxygen and carbon dioxide to survive. However, unlike adults, a child’s cardiovascular collapse is due primarily a respiratory cause or hypoperfusion, rather than a direct cardiac event.
For the EMS provider, evaluating the pediatric patient with trouble breathing is a rapid identification of respiratory distress or respiratory failure. Respiratory distress is a compensatory mechanism; the patient may present with tachypnea, accessory muscle use, and nasal flaring. Grunting may be heard, as the patient creates extra pressure at the end of the exhalation phase to help keep the lower airways open. The patient skin signs may be cool, pale and diaphoretic, and tachycardia will be present.
In contrast, respiratory failure is a decompensatory mechanism, with respiratory and cardiac arrest being its endpoint. Exhausted, the patient’s breathing slows, the level of consciousness plummets and heart rate drops dramatically. This is a critical situation that must be reversed immediately in the hopes of avoiding a full arrest state.
Upper Airway Conditions
Epiglottits is a more serious illness that requires prompt attention and careful management. Caused primarily by the Haemophilus B virus, this infection can rapidly evolve into a life-threatening condition within a few hours. A fever develops, followed by increasing lethargy, and difficulty breathing. Because the airway is essentially swelling shut, the child cannot swallow without a lot of pain and difficulty.
As a result, the patient will want to sit up and lean his head forward into a sniffing position, in order to maximize the passageway. Drooling and stridor will likely be evident. Because of immunization efforts, cases of epiglottitis have decreased nationwide; however the condition still exists and is also seen with adults as well.
Lower Airway Conditions
Bronchitis, as the name indicates, is the inflammation of the bronchioles. This is usually caused by a viral infection, such as influenza or respiratory syncytial virus (RSV). URI symptoms are usually present, and the patient usually present with a cough which may or may not be productive. As with other infections, fever will be present.
Asthma is an episodic reactive airway disease, meaning that when not under stress, the lungs show little signs of the disease. When an attack occurs, several events happen; the bronchioles constrict due to smooth muscle activation. As they constrict, air becomes trapped, causing the child to exhale with greater force than normal.
This results in an extended, or prolonged expiratory phase during breathing. If the condition is not relieved, the mucosal membranes of the bronchioles begin to swell and fluid may be released, worsening the constriction. The patient may have a rescue inhaler to help with the bronchospasm, as well as a corticosteroid inhaler to help mediate the potential for swelling on a continuous basis.
As an asthma attack begins, the patient may present with intermittent or continuous coughing as an effort to keep the bronchioles open. Tachypnea sets in, and the patient will find it harder to exhale. Intercostal muscle use and pursed lips are signs that the patient is working harder to move air in and out of the lungs.
Quickly assess for the use of any accessory muscles, and for how deep and fast the child is breathing. As soon as you can establish trust with the child, auscultate the lung fields for the presence of normal air movement, or wheezes and/or crackles. Move the small bell of your stethoscope to the later sides of the neck to detect any evidence of stridor.
If possible, use pulse oximetry and end tidal capnography for adequate signs of oxygenation and air exchange. Establish a full set of baseline vital signs, using appropriate sized equipment such blood pressure cuffs. Ascertain a quick history from the parent or guardian, paying attention to symptoms of a fever or flu-like symptoms. A reported history of a rapidly deteriorating condition is an ominous finding. Determine if the patient is taking any prescribed or over the counter (OTC) medications, and if there are any allergies to medications. Examine the body for signs of trauma, swelling, pain or tenderness.
Humidifying the oxygen can help soothe irritated soft tissues, reducing some pain and relieving distress. ALS providers may provide a beta-2 agonist such as albuterol or a combination medication such as atrovent to dilate bronchioles and improve airflow.
In dire circumstances, an advanced airway such as endotracheal intubation or cricothyrotomy may be required to prevent complete closure of the upper airway. ALS providers must train continuously in these procedures to maximize the chance of success in these extreme circumstances.
Transport of pediatric patients is essential, even those with mild signs of distress.