croup prepared by: south west education committee
TRANSCRIPT
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CROUP
Prepared by:
South West Education Committee
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South West Education Committee
Croup Protocol
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OBJECTIVES Identify the anatomical differences in
pediatrics which impact croup patients. Review of pediatric assessment Identify common presentations for
croup. Distinguish croup from Epliglottitis. Describe the treatment for croup. Explain the indications for treatment.
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ANATOMICAL DIFFERENCES
Anatomy is smaller and proportioned differently.
Head proportionately larger on a weak neck.
Obligatory nose breathers. (Infants)
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AIRWAY - Pediatric vs. Adult
Narrower at all levels The mandible is
proportionally smaller in young children
The tongue is proportionally larger than adults
Larynx is more anterior and superior than an adults’ (C3-C4)
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AIRWAY - Pediatric vs. Adult
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AIRWAY
Cricoid ring is the narrowest part of the airway in young children
Tracheal cartilage is softer
Trachea is smaller in both length and diameter
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A Picture is Worth…..
Small, hypotonic jaw, large tongue, tonsils, adenoids, arytenoids, uvula, long floppy epiglottis. (prone to swelling)
Excessive secretions. (requires suctioning) Gums are more delicate, bleed easily, softer
teeth which dislodge easily
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Anatomical Differences Why is this
difficult? The larynx:
– 3-3-2– More anterior.– More superior.
thyromental distance
– Big teeth or no teeth.
– Cone shaped.
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BLS first– Open & maintain a/w– Ensure patency
• Suction & insert oral &/or nasal a/w
– ORAL or NASAL ETT?– Assist/prep for intubation
AIRWAY
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HUMAN ERROR
Most preventable deaths that happen in the pre-hospital care setting are STILL attributed to poor airway management practices.
It has been found that upwards of 86% of preventable deaths of inhospital patients with airway complications were attributed to human error.
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PEDIATRIC REVIEWCHEST AND LUNGS
Ribs are positioned horizontally Ribs are more pliable and offer less
protection to organs Chest muscles are immature and fatigue
easily Lung tissue is more fragile Mediastinum is more mobile Thin chest wall allows for easily transmitted
breath sounds
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PEDIATRIC REVIEW ABDOMEN
Immature abdominal muscles offer less protection
Abdominal organs are closer together Liver and spleen are proportionally
larger and more vascular
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PEDIATRIC REVIEW RESPIRATORY SYSTEM
Tidal volume is proportionally smaller to that of adolescents and adults
Metabolic oxygen requirements of infants and children are about double those of adolescents and adults
Children have proportionally smaller functional residual capacity, and therefore proportionally smaller oxygen reserves
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PEDIATRIC REVIEW CARDIOVASCULAR SYSTEM
Cardiac output is rate dependent in infants and small children
Vigorous but limited cardiovascular reserve Bradycardia is a response to hypoxia Children can maintain blood pressure longer
than adults Circulating blood volume is proportionally
larger than adults Absolute blood volume is smaller than adults
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WRAP UP! Smaller chest and respiratory reserve, belly
breathers. Poorly developed accessory and abdominal
muscles. ( prone to fatigue / injury) Poorly developed rib cage. (prone injury) Excessive air swallowing. (large stomach) Poor gastric emptying. (vomit) Immature temperature regulatory system. Higher metabolic rate requires a higher
respiratory and circulatory rate. Conversely they have a much lower blood pressure due to the lack of plaque, arteriosclerosis and muscle development in arteries.
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ASSESSMENT - PEDIATRICS
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SCENE ASSESSMENT Observe the scene for hazards or potential
hazards Observe the scene for mechanism of
injury/illness– Ingestion
• Pills, medicine bottles, household chemicals, etc.
– Child abuse• Injury and history do not coincide, bruises not
where they should be for mechanism of injury, etc.
– Position patient found
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INITIAL ASSESSMENT General impression
– General impression of environment– General impression of parent/guardian and
child interaction– General impression of the patient/pediatric
assessment triangle• A structure for assessing the pediatric
patient• Focuses on the most valuable
information for pediatric patients• Used to ascertain if any life-threatening
condition exists • Components
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GCS / LOA Determine level of consciousness
– AVPU scale • Alert• Responds to verbal stimuli• Responds to painful stimuli• Unresponsive
– Modified Glasgow Coma Scale – Signs of inadequate oxygenation
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Pediatric Glasgow Coma Scale
0-1 year old >1 year old Score
Eye Opening Spontaneous spontaneous 4To shout To command 3To pain To pain 2No response No response 1
Verbal Cry, smiles, coos Appropriate words 5Cries Disorientated 4Inappropriate cry Cries/screams or inappropriate 3Grunts Grunts or incomprehensible 2No response No response 1
Motor Obeys Command 6Localizes pain Localizes pain 5Withdraws Withdraws 4Flexion Flexion 3 Extension Extension 2 None None 1
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AIRWAY AND BREATHING Airway – determine patency Breathing should proceed with adequate chest
rise and fall. Visualize/Expose chest. Signs of respiratory distress
– Tachypnea– Use of accessory muscles– Nasal flaring– Grunting– Bradypnea– Irregular breathing pattern– Head bobbing– Absent breath sounds– Abnormal breath sounds
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CIRCULATION Pulse
– Central – Peripheral– Quality of pulse
Blood pressure– 2 x Age + 80 = systolic– 2/3 the systolic = diastolic
Skin color Active hemorrhage
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TRANSITION PHASE
Used to allow the infant or child to become familiar with you and your equipment
Use depends on the seriousness of the patient's condition– For the conscious, non-acutely ill child– For the unconscious, acutely ill child do not
perform the transition phase but proceed directly to treatment and transport
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APPROACH TO PEDIATRICS Always remember there are 2 patients. Stay CALM, reassure parents and child.
– remain calm but be attentive and willing to act aggressively to reduce morbidity and mortality.
Handle child gently & explain before doing. Try to examine small children on parents lap when
appropriate. If child or parents are extremis to the point they
endanger resuscitation efforts, separate. Prevent heat stress and preserve Child’s body
heat.
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PATIENT COMMUNICATION
Try to never be alone with a pediatric patient.
Sit close, eye level, but do not overcrowd. Use toys to aid your exam. Demonstrate on parents. Offer rewards. Be direct, do not lie!!!!!!! Parents sometimes feel guilty even if they
did nothing wrong.
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HISTORY TAKING Parents of chronically ill children know the
disease better than most care givers - ask them. Ask if child has had a fever / are they hot. Hx of laboured breathing or excessive drooling. Lethargy. (A very quiet child is a scary thing) Blank staring, twitching other bizarre behavior. Poor appetite, refusal to eat, vomiting or
diarrhea recently. Increase or decrease in wet diapers. Inconsolable crying / screaming does not
recognize parents.
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FOCUSED HISTORY–CONTENT
Chief complaint– Nature of
illness/injury– How long has the
patient been sick/injured
– Presence of fever– Effects on behavior– Bowel/urine habits– Vomiting/diarrhea– Frequency of
urination
Past medical history– Infant or child under
the care of a physician
– Chronic illnesses– Medications– Allergies
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DETAILED PHYSICAL EXAMINATION
Should proceed from head-to-toe in older children Should proceed from toe-to-head in younger
children (less than 2 years of age) Depending on the patient’s condition, some or all
of the following assessments may be appropriate:– Pupils - Hydration– Capillary refill - Pulse oximetry– ECG monitoring
Is patient hypoglycemic?
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ON-GOING ASSESSMENT
Appropriate for all patients Should be continued throughout the patient care
encounter Purpose is to monitor the patient for changes in:
– Respiratory effort– Skin color and temperature– Mental status– Vital signs (including pulse oximetry measurements)
Measurement tools should be appropriate for size of child
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RESPIRATORY COMPROMISE
Several conditions manifest chiefly as respiratory distress in children including:– Upper and lower foreign body airway obstruction– Upper airway disease (croup, bacterial tracheitis, and
epiglottitis)– Lower airway disease (asthma, bronchiolitis, and
pneumonia) Most cardiac arrests in children are secondary to
respiratory insufficiency thus, respiratory emergencies require rapid prehospital assessment and management
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CROUP Laryngotracheobronchitis Common inflammatory respiratory illness
in children– Viral infection of the upper airway
Differentiation between croup and epiglottitis in the prehospital setting may be difficult
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Upper Respiratory Distress CROUP
– upper airway infection with “barking” cough.– mild to moderate respiratory distress with predominant
stridor.– may be relieved by cold air. (mist)– usually 2 - 7 years of age, Rapid onset.
Epiglottitis DEADLY EMERGENCY!!!!!• Rarely have Stridor. (inspiratory when they do)• Excessive drooling.• Absence of a “barking seal cough.”.• Preference for sitting in “sniffing position.”• Very “eerie”, quiet & obtunded look.• High grade fever.
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Upper Respiratory DistressPRESENTATION CROUP EPIGLOTTITIS
Onset Sudden Gradual Fever Slight/absent High
Sore Throat Variable Prominent Fear, Anxiety Variable Prominent Pale/Cyanosis Variable Usually
Drooling Not usual YES Cough “Barking” No Barking cough Stridor Inspiration Rare Voice Very hoarse Muffled
Pref. Position Variable “Sniffing position”
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CROUP PROTOCOLINDICATIONS
Any patient who is <8 years old .
A current Hx of upper respiratory infection.
Barking cough (seal-like)
Stridor at rest and/or Altered level of
consciousness and/or Cyanosis.
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PROCEDURE
Monitor heart rate Attach cardiac
monitor Assess pulse rate. Pulse rate must be
<200 bpm.
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PROCEDURE
Nebulized Epinephrine will not exceed 2 doses.
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WHY EPINEPHRINE?
Epi. acts on the subglottic swollen area to vasoconstrict blood vessels and reduce the swelling with the alpha 1 effects.
Salbutamol has no vasoconstrictive effects and only acts on the smooth muscles of the bronchioles with its beta 2 effects.
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PROCEDURE
Allow patient to assume position of comfort.
Reassure the patient and parents.
Administer 100% oxygen, via blow-by if needed, while preparing equipment
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PROCEDURE
Nebulize Epinephrine 1:1000 based on patients weight and age.
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EPINEPHRINE DOSING
<1y/o and <5kg 0.5 mg(0.5 ml) in 2 ml of
normal saline.
<1y/o and >5kg 2.5 mg(2.5 ml) 2 ml of
normal saline may be
added.
Age and Weight Dose
>1y/o and <8y/o 5.0 mg (5.0 ml)
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REPEAT
Repeat treatment if no improvement is observed.
Max Epinephrine treatments is 2!
No exceptions.
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TRANSPORT
ALL PATIENTS MUST BE TRANSPORTED WITHOUT DELAY.
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REASSESS - ENROUTE
Reassess every 5 minutes.
Airway Breathing Circulation Vitals And document it all.
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QUESTIONS?