pediatric medicine: seizures, croup & parents mike mcevoy, phd, nrp, rn, ccrn ems coordinator...
TRANSCRIPT
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Pediatric Medicine:Seizures, Croup & Parents
Mike McEvoy, PhD, NRP, RN, CCRNEMS Coordinator – Saratoga County, NYEMS Editor – Fire Engineering magazine
Sr. Staff RN – Adult and Peds CTICUs – Albany Medical Center
www.mikemcevoy.com
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Disclosures• None
• I don’t know how to play golf or ski
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Mike McEvoy - Books:
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www.mikemcevoy.com
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Outline• EMS and children
• Approach to pediatric patients
• Parents
• Croup
• Seizures
• Summary
• Questions
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How Many Kids?• Peds account for 5% EMS calls
– Only 10% of pedi patients require ALS
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Pediatric Patients
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Special Patients:Infants and Children
• Under 6 mos.• 6 – 12 months• 1 –3 years• 4 – 5 years• School age• Teenagers (adolescents)
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Under 6 months:
“Little fear”
• Distract with–bright lights
–noises
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6 – 12 months:
“Stranger Anxiety”
• Smile ALOT
• Distract with–bright lights
–noises
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1 – 3 years (Toddlers):“Fear of Separation”• Very difficult age• Keep with parent• Remember:
–No abstract thinking
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4 – 5 years (Preschool):
“Magical Thinking”
• Explain yourself
• Allay fears
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School aged:
“Good conceptual abilities”
• Reliable historian
• Easily separated
• Abstract thinker
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Teenagers/Adolescents:
“Body Image”
• Privacy
• Allay fear
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Pediatric Patient• Often mimic provider
• Calm, matter of fact approach is best
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Parents (1 = 2+)• Every child has a parent (somewhere)
• Some have more than one!
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Regardless of age• Youngsters nearly always with adults
• Older kids still require parental consent
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Patients/Parents Seek aMedical Professional Who Is:
• Confident• Capable• Empathetic• Communicative:
– What you think is wrong– How you will help– What will happen next
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Bottom Line:
1=2+
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Respiratory EmergenciesPrimary cause in children:
• Hospital admissions
• Death in first year of life (excepting congenital abnormalities)
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Croup (laryngotracheitis)• Viral respiratory illness characterized by
inspiratory stridor, cough, hoarseness– Barking cough in infants & young children– Hoarseness in older children & adults
• Usually mild and self-limited illness– Upper airway obstruction & death can occur
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Croup Confounders
Sometimes confused with:• Laryngitis (hoarseness only)• LTB (laryngotracheobronchitis) – extends into
bronchi with resultant lower airway s/s (wheezes, rales, air trapping) increased risk for bacterial superinfection
• Bacterial tracheitis (croup) – thick, purulent exudate with s/s upper airway obstruction
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Croup Etiology/Epidemiology• Kids 6 – 36 mo, rare > 6 yo, males 1.4:1
• Peak 10p – 4a
• RF: family hx, recurrent
• Viral – parainfluenza type 1 most common, esp. fall/winter(peak = Oct)
• Can be RSV, measles,or other viruses
• Incidence 6% (< 6 yo)
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Croup Presentation• Gradual onset 12 – 48 hours
– Initially runny nose, congestion– Progresses to fever, cough, barking, stridor
• Persists 3 – 7 days, gradually normal
• ASSESSMENT KEY = stridor degree– Stridor at rest = significant upper ao– Others keys: retractions, restlessness– Tachypnea typically = hypoxia LOC = ominous sign
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Croup Pathophysiology
• Narrowedsubglottictrachea (edema and mucus)
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Croup Pathophysiology
• Narrowedsubglottictrachea (edema and mucus)
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Croup Pathophysiology
• Narrowedsubglottictrachea (edema and mucus)
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Concerns/History• Sudden onset
• Rapid progression (< 12 hours)
• Previous croup history
• Underlying upper airway abnormality
• Respiratory comorbidities
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Croup Differentials• Fever – absence ? spasmodic croup
• Hoarseness/bark – absent in epi, FBOA
• Diff swallowing – present in epi, FBOA
• Drooling – rare in croup (10%), common in abscesses, epiglottitis (80%)
• Throat pain – more commonin epi (60 – 70%) thancroup (< 10%)
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Wesley Croup Score (0 – 17)
• LOC: WNL/sleep = 0, altered = 5• Cyanosis: none = 0, agitation = 4, rest = 5• Stridor: none = 0, agitation = 1, rest = 2• Air entry: normal = 0, = 1, marked = 2• Retractions: none = 0, mild = 1, mod = 2,
severe = 3
Score = Mild < 2, Moderate 3 – 7, Severe > 8
Wesley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978; 132:484.
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Croup Treatment• Mild cases: humidity, fever, oral fluids
• Severe: Steroids and nebulized epi– Calm and avoid agitation
– Humidified air or O2 (keep sats > 92%)
– Dexamethasone 0.6 mg/kg (max 10 mg)• Best orally (PO 1 mg/mL is foul, IV 4 mg/mL
can be mixed with syrup). If NPO, IV or IM
– Racemic epi 0.05 mL/kg (max 0.5 mL) of 2.25% soln diluted NS to 3 mL total volume
• Repeat q 15 to 20 min
– Usually improved in 30 min, epi lasts 2 hrs
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Seizures• 3 – 5% of children have a single febrile
seizure in the first 5 years of life
• 30% have additional febrile seizures
• 3 – 6% develop afebrile seizures/epilepsy
• 3.6% risk of a seizure in an 80 year life
• Highest incidence of seizures (all types) are at extremesof life
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Febrile Seizure Criteria• Convulsion associated with temp >100.4
• Child < 6 yo
• No CNS infection/inflammation
• No metabolic abnormality with neuro s/s
• No history of afebrile seizures
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Febrile Seizure Categories• Simple (benign) = 90%
– Most common– Duration < 15 min; if repetitive total < 30 min– No focal s/s
• Complex– Duration > 15 min; if repetitive total > 30 min– Focal features or postictal paresis
< 10%
< 5% Most complex kids start with first seizure
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Clinical Features: FS• 6 months – 6 years old
– Majority 12 – 18 months
• Usually 1st day of illness(may be 1st s/s)
• Often as temp is rapidly• Simple most common, generalized with
primarily clonic activity - typically facial/respiratory muscle involvement
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Etiology/Pathogenesis
Unknown; many theories:
? Fever-induced factors proconvulsant in brain development stage or genetics
? Certain brain ion channels sensitiveto temperature
? Hyperthermia inducedhyperventilation and alkalosis
What causes febrile seizures?
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Predisposing Factors:• Infection (no virus/bacteria risk)• Immunizations
– DTP: day of vaccine (5.7 x greater risk)– MMR: 8 – 14 days after (2.83 x greater)– Risk subsequent afebrile seizures or
neurodevelopmental disability unchanged
• ? Iron deficiency• Genetic (10 – 20% familial)
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Recurrent Febrile Seizures• Overall recurrence rate 30 – 35%
– Vary with age:• 50 – 65% when < 1 yo at first seizure• < 20% older children
• Most recurrences in 1st year, nearly all within 2 years. Risk Factors:– Young age at onset– Hx febrile seizures in 1° relative– Low degree fever in ED– Brief duration between fever onset & seizure
• Meds do not decrease recurrences
Most significant RF
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EMS Concerns• Meningitis/encephalitis are main concerns in
child with fever & seizures• Underlying metabolic disorder presenting as a
seizure in child is rare• Helpful predictor of prolonged seizure is focality• Prognosis is very favorable:
– Febrile seizures may recur– Long term deficit extremely unusual– Only slightly higher risk for epilepsy
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Emergency Treatment• Scene safety: meningitis?
• C-A-B’s– Capnography invaluable
• Seizures > 5 min need tx– Check glucose– Short acting benzo
• Treat fever
The longer a seizure continues, less likely it is to stop. Median FSE = 68 min; 76% were 1st time FS
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Fever Phobia
• What are some misconceptions about fevers and fever management?
• Prior studies indicated that in some populations, up to 80% of parents thought a fever above 40 C (104 F) caused brain damage. 20% thought an untreated fever would continue to increase
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“Fever Phobia”• Primary fears
– Brain damage– Coma– Seizures– Blindness– Death
• Other contributors– Technology– Pharmaceuticals
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Fever• What defines a fever?
– Rectal temp > 100.5 °F
• Fever = 1/3 pedi outpatient visits, 1/5 pedi ED visits
• Terms (Important to differentiate):– FUO (Fever Unknown Origin) > 101 x 8d– FWS (Fever Without Source) < 1w
FUO FWS
Not an emergency Immediate test/dx needed
ABX usually not indicated ABX for specific subset
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Fever Interview Questions• How measured?
• Associated s/s?
• Response to antipyretics?– Not helpful diff. infectious vs. noninfectious
• Sweating?
• Pattern?
• Exposures (people, animals, travel)?
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Fever in the Newborn• Lower fever threshold: > 100.4°F (38°C)
• Neonatal fevers (0-28d) require full workup (guidelines don’t work well)
• Fevers in young infants might (29-90d)
• Risk = SBI (Serious Bacterial Infection)
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Fever 3 months – 3 years• > 102.2 °F (39°C) warrants evaluation• Haemophilus influenzae type b (Hib) and PNA
vaccines dramatic in cases• > 101.3 rarely associated with teething• Cause usually easy to find (56%)
– Viral (90% = OM)– Bacterial = UTI (females > males)– PNA cases usually have resp s/s on exam
• Oximetry more useful than RR
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Physical exam: Rash?
• Presence of meningealsigns in older kids, oftenabsent in infants
• Hemorrhagic rash
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Toxic?Toxicity is a clinical syndrome:
1.Lethargy with poor perfusion (cap refill > 2 seconds)
2.Cyanosis or other signs of respiratory distress AND
3.Cold hands/feet,limb pain, mottlingor pallor
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Antipyresis• Many parents aim for “normal”
temperature– Daycare, school, work can drive this
• Antipyresis therapy DOES NOT– Reduce morbidity or mortality from a febrile
illness– Decrease the recurrence of febrile seizures
• Antipyresis DOES– Relieve discomfort– Decrease insensible fluid loss
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Arguments against antipyresis• Fever is not an illness• Most fevers are short-lived and benign• Fever may protect the host• Degree of fever ≠ severity of illness fever may obscure diagnostic signs• No evidence that kids with fever are at risk
of adverse outcomes such as brain damage• Adverse effects of antipyretics outweigh
benefits…
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FEVER and ILLNESS
• Antipyretics may prolong course of illness:– Adults with rhinovirus shed the virus longer– Children with varicella have delayed time
for lesions to crust (about 1 day)– Children with malaria take longer to clear
parasites (75 vs 59 hours)
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Therapeutic intervention• Single or combination therapy
– Acetaminophen – Ibuprofen– Single regimens (of either acetaminophen or
ibuprofen) should be adequate for discomforts due to fever
• Remember therapeutic endpoint!– Most studies have evaluated antipyretic efficacy – Very limited data related to discomfort
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Summary• 1 = 2+
• Croup = viral illness 6 mo-3 yo, onset12-48 h with insp. stridor, barking cough
• Degree of stridor = severity• Tx: humidity, fever, fluids (steroids/racemic epi)
• FS: 6 mo-6 yo (most 12-18 mo), first day of illness, 90% simple FS
• Stay calm, reassure
• Consider causes, tx any FS > 5 min
![Page 55: Pediatric Medicine: Seizures, Croup & Parents Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, NY EMS Editor – Fire Engineering magazine](https://reader035.vdocuments.us/reader035/viewer/2022062518/56649cb05503460f94974799/html5/thumbnails/55.jpg)
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