initial assessment of respi. emergency (pkgdi medan)

8/12/2019 Initial Assessment of Respi. Emergency (PKGDI Medan)

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Initial AssessmentRespiratory Emergency In

Children And Its Management

Tatty Ermin Setiati

Diponegoro University

Dr. Kariadi HospitalSemarang


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Introduction (1)

Respiratory diseaseMost frequent medicalemergency, need early intervention to decrease

mortality

Initial assessment is a very important todifferentiate upper or lower respiratory

emergency

Pediatric Assessment Triangle (PAT)an easyand fast initial assessment to measure the severity

of the disease, and begin inflammatory treatment


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Introduction (2)

Specific treatment for airway obstruction after

PAT and ABCDE assessment should be given

Positioning, suctioning, non-invasive and invasiveairway management, and pharmacologic

treatment (Nebulizer, Antibiotics)

Oxygen therapy according to the need


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Initial Assessment

PATDifferentiate Respiratory Distress,

Respiratory Failure, and Respiratory Arrest

APPEARANCE

WORK OF

BREATHINGCIRCULATION

Conciousness

Core-Skin Temp. Different

Capillary refill

Warm or cool skin

Resp. Rate

Retraction


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Appearance (Tickles = TICLS)

Tonus

Interactive ness

Consol ability

Look/Gaze

Speech/Cry


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Characteristic of Circulation to Skin

Pallor

Mottling

Cyanosis

Capillary Refill Time >

Circulation to Skin


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Normal capillary refill is < 2 seconds in a warm environment


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Circulation to Skin

PAT : Potential Respiratory Failure

Normal Increased

Normal


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Circulation to Skin

PAT : Respiratory Failure

AbnormalIncreased

or

decreased

Normal or abnormal


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Rate

Effort / mechanics Air entry

Skin color and temperature

Rapid Cardiopulmonary Assessment

Physical ExaminationBreathing


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Respiratory Rate

In non-critical: RR determine by sitting the child

in his caregivers lap and exposing his chest

RR may be affected by level of activity, fever,anxiety, and metabolic state

RR > 60x / minuteabnormal in any age

RR < 20x / minute in a sick child < 6 years and 94%oxygenation probably good SaO2 < 90% in a child on 100% oxygen NR mask

need assisted ventilation

Interpret SaO2 together with WOB


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Circulation Heart Rate

TachycardiaEarly sign of hypoxia or low

perfusion, but may also caused by : fever, anxiety,

pain, excitement

A trend of increasing or decreasing HR

worsening hypoxia or shock or improvement after

treatment Bradycardiacritical hypoxia and or ischemia


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Circulation Pulse quality

Normally the brachial pulse is palpable inside or

medial to the biceps (weak / strong)if strong

probably not hypotensive

If peripheral pulse not palpated, check the central

pulse (femoral / carotid)

Absent of a central pulseCPR


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Skin Temperature

Capillary Refill Time

The child skin warm near the wrists and ankles -

good perfusion

Decreasing perfusionthe line of separation

from cool to warm advances up the limb

Capillary refill time (N 2-3 seconds), affected by

environmental factorscool room temp

Circulation to the skin (skin temp., capillary refilltime, pulse quality)assessment circulatory

status


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Rapid Cardiopulmonary Assessment

Physical Examination : Breathing


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Respiratory Arrest

Absence of effective breathing

If ventilation and oxygenation are not adequately

support

Cardio respiratoryArrest

a lowprobability of survival


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General Non-invasive

Treatment Positioning

Patient position of comfortSevere upper

airway obstruction may get into sniffing position

Severe lower airway obstructionTripod posture

Infants and Toddlerscaregivers arms or lap


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The sniffing position

The abnormal tripod position

Retractions


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Oxygen

Treatment with High flow O2safe

Give oxygen to any child with clinical signs of

cardiopulmonary distress, or with a historysuggesting possible abnormalities in gas exchange

When treating children, it is better to overuse

oxygen than to underused it


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Management of Respiratory Failure

Initially treat with general noninvasive measures Upper or lower airway obstructionspecific

treatment

Altered level of consciousness and signs of

or

WOB (flaring, grunting, gasping, apnea, cyanosis)

and or SaO2 < 90% on 100% NR O2 mask

Assisted Ventilation or PPV with BVM

ventilation or ET intubation

Placement of OG or NG tube (relieve gastric

distension and improve ventilation)


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BVM Ventilation

The best technique for providing oxygenation and

ventilation during resuscitation and transport

60-95% O2 can be given effectively and safely by

choosing a well-fitted mask, connecting with O2

reservoir to an oxygen source at 15L/ minute


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How To Use

Resuscitation Mask


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Possible Complications

BVM Ventilation Hypoxia

Barotraumas

Gastric Distension

Emesis and Aspiration


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Endotracheal Intubation (ETT)

Potential Advantages: Definitive Airway Control,Decrease Risk of Aspiration, Ease of assisted

ventilation

Potential Complications: Transient hypoxia,hypercarbia (due to prolonged intubation

attempts), elevation if intracranial pressure,

mechanical trauma of the airway, misplacementof the tube (intrabronchial / esophageal

intubation)


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DOPE

Intubated patient fail to respond (improve color,

SaO2, HR, and appearance)

Dislodgment

Extubate, BVM, Reintubate ObstructionSuction, Extubate, BVM,

Reintubate

PneumothoraxNeedle thoracocentesis

EquipmentCheck equipment patient-to-tank


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Specific Treatment

For Respiratory Distress

Determine upper or lower airway obstruction

Snoring or stridorupper airway obstruction

Wheezing

lower airway obstruction Upper airway obstruction due the tounge and

mandible falling back/ partially blocking the

pharynx

head tilt / chin-lift or jaw trust Maintenance of adequate airway: Placement of an

oropharyngeal airway, nasopharyngeal or ETT


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Croup

A viral disease with inflammation, edema,

narrowing of the larynx, trachea, and bronchioles

Affects infants and toddlers Cold symptoms several days followed by the

development of a barking cough, str idor, various

level of respiratory distress

Fever and symptoms are worse at night


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Croup Treatment

Cool mist (humidified oxygen or nebulizedsaline)

Cool water vapor reduced the inflammation and

obstruction

Pharmacologic treatment: Nebulized epinephrine

(stridor, WOB, poor air movement, SaO2 12 months

Appears ill, Toxic, Pain on swallowing, Stridor

may be present, no barking cough

Examples: Epiglotitis ( H. Influenzae), Tracheitis,

Diphtheria, Peritonsillar Abcess, Retropharyngeal

Abcess

Treatment : General noninvasive dgn high flowoxygen and position of comfort. In RF give BVM

consider ETT


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Lower Airway Obstruction

(Bronchiolitis)

Bronchiolitisviral lower respiratory infection,

usually in children < 3 years caused by RSV

Destruction lining of the bronchioles, profusesecretions, bronchoconstriction

Assessment shows variable degrees of WOB,

tachypnea, diffuse wheezing, insp. Crackles,

tachycardia


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Asthma

Asthma is a disease of small airway inflammation

leads to bronchoconstriction, mucosal edema, and

profuse secretions

Severe airway obstruction and V/Q mismatch

ClinicallyDifferent degrees of tachypnea,

tachycardia, WOB, wheezing on exhalation,SaO2 normal or low


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Asthma with RF

Altered appearance

Exhaustion

Inability to recline Interrupted speech

Severe retraction

Decreased Air Movement


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Management

Lower Respiratory Obstruction

General noninvasive treatment with high flow O2

therapy

Nebulized Bronchodilators

In asthma : Assisted VentilationPPV required

very high insp. Pressure may caused

pneumothorax/pneumomediastinum

BVM ventilation or ETTIf RF and failed torespond to high flow O2 and maximal

bronchodilator therapy


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Summary (2)

Specific treatment for croup cool mist and

nebulized epinephrine

If RF occurred begin with assisted ventilation

with BVM at an age-appropriate rate

Add spesific treatment for airway obstructed if

indicated

Performed ETT, and be alert for DOPE in the

intubated child who suddenly worsens / fails torespond


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initial assessment of respi. emergency (pkgdi medan)

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