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CROUP. Prepared by: South West Education Committee. South West Education Committee. Croup Protocol. OBJECTIVES. Identify the anatomical differences in pediatrics which impact croup patients. Review of pediatric assessment Identify common presentations for croup.

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croup

CROUP

Prepared by:

South West Education Committee

objectives
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.
anatomical differences
ANATOMICAL DIFFERENCES
  • Anatomy is smaller and proportioned differently.
  • Head proportionately larger on a weak neck.
  • Obligatory nose breathers. (Infants)
airway pediatric vs adult
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)
airway
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
a picture is worth
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
anatomical differences9
Anatomical Differences
  • Why is this difficult?
  • The larynx:
    • 3-3-2
    • More anterior.
    • More superior. thyromental distance
    • Big teeth or no teeth.
    • Cone shaped.
airway10
AIRWAY
  • BLS first
    • Open & maintain a/w
    • Ensure patency
      • Suction & insert oral &/or nasal a/w
    • ORAL or NASAL ETT?
    • Assist/prep for intubation
human error
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.
pediatric review chest and lungs
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
pediatric review abdomen
PEDIATRIC REVIEW ABDOMEN
  • Immature abdominal muscles offer less protection
  • Abdominal organs are closer together
  • Liver and spleen are proportionally larger and more vascular
pediatric review respiratory system
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
pediatric review cardiovascular system
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
wrap up
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.
scene assessment
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
initial assessment
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
gcs loa
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
pediatric glasgow coma scale
Pediatric Glasgow Coma Scale

0-1 year old >1 year old Score

Eye Opening Spontaneous spontaneous 4

To shout To command 3

To pain To pain 2

No response No response 1

Verbal Cry, smiles, coos Appropriate words 5

Cries Disorientated 4

Inappropriate cry Cries/screams or inappropriate 3

Grunts Grunts or incomprehensible 2

No response No response 1

Motor Obeys Command 6

Localizes pain Localizes pain 5

Withdraws Withdraws 4 Flexion Flexion 3 Extension Extension 2 None None 1

airway and breathing
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
circulation
CIRCULATION
  • Pulse
    • Central
    • Peripheral
    • Quality of pulse
  • Blood pressure
    • 2 x Age + 80 = systolic
    • 2/3 the systolic = diastolic
  • Skin color
  • Active hemorrhage
transition phase
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
approach to pediatrics
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.
patient communication
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.
history taking
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.
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

FOCUSED HISTORY–CONTENT
detailed physical examination
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?
on going assessment
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
respiratory compromise
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
croup32
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
upper respiratory distress
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.
croup protocol indications
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.
procedure
PROCEDURE
  • Monitor heart rate
  • Attach cardiac monitor
  • Assess pulse rate.
  • Pulse rate must be <200 bpm.
procedure37
PROCEDURE
  • Nebulized Epinephrine will not exceed 2 doses.
why epinephrine
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.
procedure39
PROCEDURE
  • Allow patient to assume position of comfort.
  • Reassure the patient and parents.
  • Administer 100% oxygen, via blow-by if needed, while preparing equipment
procedure40
PROCEDURE
  • Nebulize Epinephrine 1:1000 based on patients weight and age.
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.

EPINEPHRINE DOSING

Age and WeightDose

>1y/o and <8y/o 5.0 mg (5.0 ml)

repeat
REPEAT
  • Repeat treatment if no improvement is observed.
  • Max Epinephrine treatments is 2!
  • No exceptions.
transport
TRANSPORT
  • ALL PATIENTS MUST BE TRANSPORTED WITHOUT DELAY.
reassess enroute
REASSESS - ENROUTE
  • Reassess every 5 minutes.
  • Airway
  • Breathing
  • Circulation
  • Vitals
  • And document it all.