Pediatrics | Paramedicine 101

Croup/Epiglottitis

12/19/2010 by Adam Thompson, EMT-P 6 Comments

There is nothing scarier than a sick kid. I am becoming more and more obsessed with educating myself on pediatric emergencies. This is because of that fear, and the fact that I find it is one of those areas that I am less versed in. This post is aimed at identifying and treating the child who presents with an upper respiratory infection (URI) like croup or epiglottitis. These kids sound sick, look sick, and may get even sicker.

As always, aggressive airway management may be indicated if the child appears to have impending respiratory failure. Signs of this include severe hypoxia, bradycardia, and decreasing respiratory effort.

If the patient doesn’t present with imminent signs like those mentioned above, it is pertinent to obtain a good medical history.

History:

Has the child ever had a URI in the past?

- If so, did he/she present like this?

Was the onset acute or gradual?

- Epiglottits generally presents with an acute onset.

Has the child been sick, and is he up to date with vaccinations?

- Most cases of epiglottitis are caused by haemophilus influenza or H.flu

Has the child ever been intubated?

- This helps identify whether you will need to be aggressive, and a recent intubation could be the cause of hoarseness.

Epiglittits is actually inflammation of the epiglottis–you know, that flap that covers the trachea during swallowing? If this becomes inflamed, it swells, and that swelling could cause a partial or even a complete occlusion of the trachea, thus compromising ventilation.

- Usually febrile, without cough

- Patient may be in tripod position

- Drooling present

Treatment

- Immediate intubation may be indicated (may be very difficult!)

- Epinephrine may be administered in extremis

Croup or laryngotracheobronchitis is also an upper respiratory infection that may be mild, moderate, or severe. It tends to be worse at night, and is most commonly identified by the classic “seal-bark cough”.

- Inspiratory stridor & “barking cough”

- Often preceded by flu

- More likely if they have had croup before

Treatment

- Oxygen therapy

- Nebulized Saline

- If severely hypoxic, racemic epinephrine may be indicated.

- It is often taught to take these children outside, into colder air

So who is in extremis?

- The severely hypoxic child: Cyanosis, bradycardia

- Intercostal retractions with decreasing stridor is an ominous sign of impending respiratory failure

- Decreasing mental status means decreasing respiratory drive. TREAT AGGRESSIVELY

****

Check out Justin, The Happy Medic, Schorr’s last run-in with croup in THIS POST.

Filed Under: Airway, Airway Management, Education, Medical Emergencies, Pediatrics

Little. Adults.

10/22/2010 by thehappymedic Leave a Comment

Your second patient is behind you, frightened, confused and alone.

While your attention is on the child with the cough and the panic on your face is palpable, keep in mind that every pediatric call involves at least 1 if not 2 additional patients: the parents.

They have been awake for hours trying to calm their child who has been feeling ill, coughing, not eating. Work, play, chores and errands have all ground to a halt while the little one recovers.

But for whatever reason, be it a change in condition or sheer exhaustion, you are now involved in the care of this little person.

Don’t be intimidated by your instructors when they pound into your head that “kids are NOT little adults!” they really are. They have the same body systems, you’re going to give them all the adult drugs, just in smaller doses. Sure their physiology is different than adults, that’s why we dose them differently, but don’t get stuck sweating and screaming, especially with a tired, confused and concerned parent behind you.

Your second patient needs to be reassured and calmed. Your instinct may be to get hands on with the child and do your “Paramedic thing” but what will you learn from a screaming, thrashing child you can’t learn from a shy, tired, comfortable in mother’s arms child? We learn that a child who is not afraid of us is sick and this can be your initial assessment surely, but also look around the room to find out what the last 12-36 hours have been like.

Are there piles of tissues scattered around the house? Is dad sniffling and coughing as well? Are there medication bottles around, bulb syringes, humidifiers? All of this environmental information needs to be absorbed and decoded as you walk through the house or while reaching for your bag.

All those tissues were used by a tired parent to treat a sick, unhappy child. Ever tried to wipe the nose of a 1 year old? Every 5 minutes? The parents are nodding and smiling, the folks without kids are wondering how hard it can be.

This topic became fresh in my mind when my 4 year old developed croup last December. She had had the sniffles for a few days over the Christmas holiday and on the last day of our vacation she fell asleep early. She had been lethargic, but not overly so, just tired. Around 8pm she started a coughing fit that would not end for over 3 hours. Her “barking, seal like” cough was as described in the books, but what they don’t describe is the sheer terror on her face when she can’t even stop coughing long enough to speak, drink or eat. We tried cough syrup, steam, cold air, breathing exercises, even her sister’s inhaler (metered for a smaller child) with no success. She couldn’t even cry the coughing was so bad. With no other options and the hour getting late, I chose to take her to the only medical care open that late, not just to treat her, but to let the rest of the family get some much needed rest.

At the local Pediatric ER they tried to get her to wear a mask because of her cough. Tried. We waited outside instead. When we finally got inside the respiratory techs gave her 10mg of albuterol (16kg remember) over 30 minutes with no change in symptoms, something I told them we had tried without success.

I was at the end of my rope. Tired, hungry and confused I waited for someone, anyone to treat her. It was right then that it clicked for me what parents who call for my help are going through. I called for help and no one is telling me, or my sick child, what is happening or when it will stop. She was a trooper for another 30 minutes and when they finally decided to give a steroid, I was relieved. But no one even bothered to explain things to me, and I knew what was going on because of what I do. Imagine if I had no medical training.

Had the staff explained things to me, walked me through the options ahead of time or even sat down or offered to bring me something, since there was no way I was leaving my daughter’s side, I would have been better prepared to help her recover.

That parent behind you trying to wipe the snot from Jr’s nose isn’t in your way or second guessing your treatment, they’re simply doing everything they know how to do to make their child feel better. Let them.

Explain your actions using a soothing voice. While dosages are racing through your head, mention good things you see. Focus on the positive and that parent will become a resource instead of a second patient.

When my eldest developed the cough last night I had a feeling we would be up early waiting for the meds to kick in. Not until 630 am did the codeine finally calm the cough from constant to intermittent, but by then her younger sister was awake and the sun about to rise. But my little one is being treated with adult medication in littler dosages and when she hugs me and can finally take a breath and say “thank you” the hours of hurt watching her cough melt away.

If you come to my house to help her, don’t ignore me. I can help if you just tell me how.

Filed Under: Assessment, Pediatrics, Respiratory

The vomiting toddler

02/18/2010 by Adam Thompson, EMT-P 3 Comments

You just received a dispatch to a working class neighborhood townhouse for a two year old vomiting. Great. Another BS call. “Why does a parent call EMS because her kid is simply vomiting?”, you ask your partner as you pull up the residence. The residence appears neat on the outside but the inside is cluttered but clean. The mother, obviously pregnant in her third trimester, holding the girl, tells you her daughter has been vomiting for the past hour or so and also had diarrhea. She apologized for calling you but she was concerned that the child had emesis x5 in the short time she was sick, and she was not sure but felt she saw blood in her liquid stool. Not only that, she says she is not acting right. She would have taken her to the hospital herself but she is snowed in from the heavy snow fall.

As you approach the child, she makes eye contact with you but seems a little listless and pale. She appears to be of normal weight and build for a 2 year old. She lets you take vitals with mother present. R24, normal and non labored; PaO2 98%; P110, S/R; BP 80/p (you still haven’t whipped out the bad habit of your partner of getting a palp pressure as an initial on scene pressure); T 37C. Skin is a warm and dry with poor turger and cap refill of 3 seconds.

Mother states the patient has no PMX, was born full term with no complications or congenital defects, and immunizations are up to date. Mom stated the child ate breakfast of cereal and had a P&J sandwich for lunch with chocolate milk. In fact, she says embarrassingly, that she found her already awake in the kitchen helping herself to a box of Count Chocula when she awoke in the morning, with pantry cabinets open. When asked about potential ingestion of cleaning materials, she stated no, as they are under the sink secured by a latch that the child has not yet been able to open.

What other scene survey and/or patient assessment findings would you like to know?

So, what is the differential diagnoses?

What prehospital treatment does this kid need?

What is the appropriate destination for this kid?

If you have a suspicion, who will you call for consult?

What treatment will this kid get in the ER?

Filed Under: Clinical Discussion, Pediatrics, Toxicology

Blue Babies

11/10/2009 by Adam Thompson, EMT-P 3 Comments

Blue Babies

I am not an expert when it comes to pediatric emergencies. The mean age of most of my patients is over 50, and the kid calls are far and few between… well usually. In the past two shifts I have had two unstable kids. When it comes to cardiac or adult respiratory calls, I am top notch. My comfort level doesn’t go far below the age of 16. I handled the calls efficiently of coarse, but with an added sense of pucker. This has initiated a need for further education.

So let me provide some information on the two congenital conditions these kids suffered from.

Hypoplastic Left Heart Syndrome

In a child with Hypoplastic Left Heart Syndrome, all of the structures on the left side of the heart (the side which receives oxygen-rich blood from the lungs and pumps it out to the body) are severely underdeveloped.

The mitral and aortic valves are either completely “atretic” (closed), or they are very small. The left ventricle itself is tiny, and the first part of the aorta is very small, often only a few millimeters in diameter.

This results in a situation where the left side of the heart is completely unable to support the circulation needed by the body’s organs, though the right side of the heart (the side that delivers blood to the lungs) is typically normally developed.

What will we see in the prehospital environment?

Chronic hypoxia. Most-likely, your patient will already be diagnosed, and hopefully receiving the needed treatments.

What is the definitive treatment?

The management of the newborn with Hypoplastic Left Heart Syndrome can be divided into the initial stabilization period and the operative / post-operative period.

Even while diagnostic tests may be going on, the rapid stabilization of infants with Hypoplastic Left Heart Syndrome must begin as soon as the diagnosis is suspected.

Catheters are placed, usually in the umbilical blood vessels, which allow medications to be given and blood to be obtained for testing. An infusion of prostaglandin, a medication that prevents the patent ductus arteriosus from closing, is begun, thus maintaining the pathway for blood to reach the body from the right ventricle.

Even though the infant may have low oxygen saturations, supplemental oxygen is avoided since it tends to promote more blood flow to the lungs which may steal blood flow from the body and place excessive demands on the already stressed single right ventricle.

Manipulations of medications and respiratory treatments (including possible mechanical ventilation) are performed to optimally balance the flow of blood to the body and the flow of blood to the lungs.

Close monitoring is essential to detect any organ dysfunction and maintain cardiopulmonary stability because infants with this anomaly may be very unpredictable and undergo quite sudden changes.

There are essentially three treatment options that have been proposed for children with Hypoplastic Left Heart Syndrome.

In the past, due to poor outcomes with available treatments at that time, no treatment was often recommended. Today it is rare that a family may choose not to treat a child with Hypoplastic Left Heart Syndrome, though in cases when the infant is unable to be satisfactorily stabilized no treatment may be advised.

Cardiac transplantation in the newborn period is performed as primary treatment for Hypoplastic Left Heart Syndrome at some centers in this country. While transplantation has the advantage of replacing the very abnormal heart of a child with Hypoplastic Left Heart Syndrome with one of normal structure, this treatment is limited by the scarcity of newborn organs available for transplantation and the life-long need for anti-rejection therapy. Additionally, although outcomes for transplantation continue to improve, and the incidence of rejection is lowest in patients transplanted as newborns, the average life span of the transplanted heart is limited (currently less than 15 years).

The most commonly pursued treatment for Hypoplastic Left Heart Syndrome is “staged reconstruction” in which a series of operations, usually three, are performed to reconfigure the child’s cardiovascular system to be as efficient as possible despite the lack of an adequate left ventricle. These surgeries do not correct the lesion, and are instead considered “palliative”.

The first operation in the staged approach is known as the Norwood operation and is typically performed in the first week of life. With the Norwood operation, the right ventricle become the systemic or main ventricle pumping to the body. A “new” or “neo” aorta is made from part of the pulmonary artery and the original, tiny aorta, which is reconstructed / enlarged to provide blood flow to the body. Finally, to provide blood flow to the lungs, a small tube graft is placed either from an artery to the lung vessels (called a modified Blalock-Taussig shunt) or from the right ventricle to the lung vessels (called a Sano modification). Because of the extensive reconstruction of the aorta that must be done, this operation is one of the most challenging heart surgeries in pediatrics.

The subsequent operations in the staged reconstruction plan are the bi-directional Glenn procedure, typically done at 3 to 6 months of age, and the Fontan operation, typically done in children older than 2 or 3 years. These operations are described in more detail in the Heart Encyclopedia chapter on “Single Ventricle Cardiac Anomalies.”

“Blue Baby Syndrome”

The first heart surgery ever done was on a blue baby at Johns Hopkins. There is a great movie about this Something The Lord Made, which I highly recommend.

Hypoplastic Left Heart Syndrome is a form of “Blue Baby Syndrome” as well as the following:

Tetralogy of Fallot – Pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy.

Dextro-Transposition of the Great Arteries (d-TGA) – With d-TGA, blue blood from the right heart is pumped immediately through the aorta and circulated to the body and the heart itself, bypassing the lungs altogether, while the left heart pumps red blood continuously back into the lungs through the pulmonary artery.

Tricuspid Atresia – Complete absence of the tricuspid valve.

Most information and images courtesy of Wikipedia.

Filed Under: Cardiology, Education, Pediatrics

PediCap Product Recall

08/27/2009 by Adam Thompson, EMT-P 3 Comments

This is the Pedi-Cap.

For comparison, here is the Pedi-Cap next to its big brother/sister, the Easy Cap II.

It is tiny. To give you another idea of the size, here it is being used on an itty-bitty baby, who could fit in my hand.

Photo credit

This device is a simple piece of litmus paper. CO₂ (Carbon diOxide) is acidic. In the presence of CO₂, this paper will change from Purple to Yellow. The concentration of CO₂ determines how yellow the paper becomes.^[1]

Some of the problems with this are due to it being nothing more than a piece of litmus paper with a supposedly airtight plastic cover, airtight except for the connections. When litmus paper becomes moist, it does not do what we want it to do in the presence of CO₂. It does not tell us if there is any CO₂ present.

We are looking for the CO₂ because that indicates that the tube is connected with a place that either has a reservoir of CO₂, or to a place that is capable of exchanging CO₂ for O₂ (Oxygen).

If you have been providing mouth-to-mouth ventilation, but have been filling the belly, rather than the lungs, that would be one source of a CO₂ reservoir at the end of the esophagus. After a while, the CO₂ should be removed. In the mean time, you may be misled into leaving the tube in the esophagus and ventilating the stomach. This may not turn out well.

Contraindications
• Not to be used for detection of hypercarbia.
• Not to be used to detect main stem bronchial intubation.
• Not to be used during mouth-to-tube ventilation.
• Should not be used to detect oropharyngeal tube placement.
Standard clinical assessment must be used.^[2]

This is a description of a problem with the Pedi-Cap.

Began ventilating patient with pedi-cap and peds ambubag. Patient began to desaturate immediately. Could not force air thru ambu with Pedicap on. Removed pedi cap and ventilation was accomplished. O₂ sats improved. Manufacturer response (as per reporter) for CO₂ detector, Pedi-Cap “size of the paper in the detector was dimensioned incorrectly causing the device to have a higher flow resistance.” Testing other lots to see if same problem exists.^[3]

Let’s look at this step-by-step.

Began ventilating patient with pedi-cap and peds ambubag.

No problem, yet.

Patient began to desaturate immediately.

Not a good sign. PALS (Pediatric Advanced Life Support) teaches a 4 step assessment for sudden deterioration of an intubated patient using the mnemonic DOPE (not something to say out loud in front of family). D = Dislodged; O = Obstructed; P = Pneumothorax; E = Equipment failure.

Could not force air thru ambu with Pedicap on.

That would be D for Dislodged. E does not really apply, since that is supposed to be for patients on a ventilator, but use whatever works.

Removed pedi cap and ventilation was accomplished.

Problem solved, but I am guessing that the reason for the assessment of CO₂ has not been addressed.

O2 sats improved.

I’m assuming that the CO₂ was evaluated in some way. Maybe they just kept ventilating and figured that the response to ventilation with bagging was confirmation enough. The immediate improvement in oxygen saturation is unlikely to be a false positive.

Manufacturer response (as per reporter) for CO2 detector, Pedi-Cap “size of the paper in the detector was dimensioned incorrectly causing the device to have a higher flow resistance.” Testing other lots to see if same problem exists.

Image modified from the Nellcor product manual.

Nice work by the person ventilating the patient in quickly recognizing a problem and reacting appropriately.

August 14, 2009

Dear Valued Customer,

We are informing you of an urgent voluntary medical device recall regarding the PediCap End-Tidal CO2 Detector (PediCap and PediCap 6).

We have received a customer report in which they experienced difficulty manually ventilating an intubated patient through the PediCap. While we continue to investigate, we believe that a recent modification to the PediCap End-Tidal CO2 Detector may result in increased resistance to airflow through the PediCap. This could result in ineffective ventilation of the patient and/or inadequate detection of CO2 levels, so that the indicator paper will not change color.

Although we have received no reports of patient injury, we have determined that all PediCap and PediCap 6 End-Tidal CO2 Detectors from the lots listed below must be returned. We are requesting your assistance in conducting this activity. Please review your inventory and segregate any product with the affected lot numbers and return affected product according to the directions below^[4]

Likewise, it is nice to see a company responding with a recall, rather than waiting for a patient to be injured. Only one week between the FDA notice and the company recall. While it could be faster, some companies will keep denying problems even after there are a bunch of dead bodies from their product.

Footnotes:

^ ¹ CO₂ detection sheet
Nellcor
Free PDF

^ ² Pediatric End-Tidal CO2 Detector PediCap®
Nellcor
Free PDF

^ ³ FDA Medical Product Safety Report
FDA
08/07/2009
I cannot get Blogger to accept the html for a link to the FDA page. Cut and paste this link:

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/medsun_details.cfm?ID=%25″-O%3D%25_X%20%0A

^ ⁴ URGENT MEDICAL DEVICE RECALL for PediCap™ End-Tidal CO2 Detectors
Covidien (owner of Nellcor)
August 14, 2009
Free PDF

All necessary information, to contact the company, is in the pdf. Also included are the numbers of all of the lots involved.

Filed Under: Airway Management, Critical Judgment, Pediatrics, Rogue Medic

Croup/Epiglottitis

Little. Adults.

The vomiting toddler

Blue Babies

PediCap Product Recall

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Croup/Epiglottitis

Little. Adults.

The vomiting toddler

Blue Babies

PediCap Product Recall

Sponsor

Recent Comments

Archives

Categories

Blogroll