4.1 Pediatric Respiratory Distress/Failure and Shock Flashcards
Respiratory Distress
- Symptoms related to trouble breathing
- Caused by infection, obstruction, chronic lung diseases, etc.
- Children de-compensate much faster than adults.
- Children have smaller airways to to be obstructed
- Children have fewer alveoli
- It is harder for children to compensate for breathing muscularly due to immature muscles
Early Signs of Respiratory Distress
- EARLIEST INDICATOR IS RESTLESSNESS (neurological response to hypoxia)
- Irritability (hypoxia)
- Tachypnea (Compensation)
- Tachycardia (Compensation)
- Diaphoresis
Increased work of breathing (use of accessory muscles, mechanics, air exchange)
- Nasal Flaring
- Retractions
- Grunting/Wheezing
- Dyspnea
- Head Bobbing
Nursing Care for Early Respiratory Distress
- Early recognition is key to prevent it from progressing to respiratory failure
- Positioning upright or tripod position to give more range to expand lungs
- Clear airway with suctioning if there is an obstruction
- Oxygen administration (high flow oxygen if needed)
- LOOK FOR CAUSE OF RESPIRATORY DISTRESS (airway obstruction, edema, foreign body, bronchoconstriction)
- Continue to monitor patient for symptoms getting worse
- ADMINISTER OXYGEN IF LEVELS DROP BELOW 94%
- If interventions are not working, call the alert rapid response team
Respiratory Distress Progression
- Respiratory distress -> respiratory failure -> respiratory arrest -> cardiac arrest
(Can happen within minutes)
Signs of progression
Compensatory mechanisms are no longer working
- Tachypnea turns to bradypnea
- Tachycardia turns to Bradycardia
Cyanosis
- Pediatrics may turn pale or grey color instead of cyanosis
LOC - Stupor, unresponsiveness or slipping into coma.
MOST PIEDATRIC CARDIAC ARREST BEGIN AS RESPIRATORY FAILURE
Respiratory Failure
- Inability of respiratory system to maintain adequate oxygenation/ventilation to surrounding tissue
- Happens when compensatory mechanisms fail to maintain gas exchange (decompensation)
HALLMARK OF RESPIRATORY FAILURE IS CHANGE IN MENTAL STATUS
- Caused by decrease in O2 and increase in CO2
- Increase in CO2 has a sedative effect
Signs
- Desaturation, cyanosis despite supplemental O2
- Increased effort with poor air entry (gasping, head bobbing, see-saw respirations, obstructive stridor)
Apnea - Cessation of breathing >20 seconds or <20 seconds with change in color, HR and muscle tone
Shock
- Shock is inadequate delivery of oxygenated blood to tissue to meet metabolic demands
Early Shock (child still compensates)
- Tachycardia and systemic vasoconstriction to increase cardiac output and perfusion to tissue
- Shunting of blood to more vital organs (brain, heart) and away from microcirculation (kidneys, skin, gut)
End Organ Perfusion - Changes in mental status, capillary refill, skin temp/color, urine output
Early Signs
- Normal BP
- Narrowed Pulse Pressure
- Unexplained mild tachycardia
- Thirst
- Pallor
- Prolonged Capillary Refill
- Change in LOC (restlessness, irritability, agitation)
LATE SIGNS OF SHOCK
- Decompensation (compensation mechanisms no longer work)
- MOST COMMON SIGN OF LATE SHOCK IS HYPOTENSION
Differences between Early Shock and Late Shock
- Degree of tachycardia and perfusion to extremities
- Level of consciousness
- BP (10% drop in BP is SIGNIFICANT - HYPOTENSION)
Late signs of shock is dangerous sign of progression from cardiovascular failure to arrest within minutes
Cause of Cardiac Arrest in Pediatrics
- Respiratory Insufficiency
- Hypotension (Shock)
- Sepsis
Respiratory Distress
- Use of compensatory mechanisms to maintain adequate oxygenation
- Consists of rate and work of breathing
SIGNS
- Retractions (sternal or intercostal)
- Use of accessory muscles (in the neck)
- Grunting/Wheezing
- Anxious
- Child who wants to sit upright instead of lying down
Respiratory Failure
- Inadequate oxygenation and ventilation when compensatory mechanisms fail to maintain gas exchange
- Can be caused by respiratory distress OR poison (depresses mental status), seizure, severe weakness.
- HALLMARK - Change in Mental Status
Signs
- Cyanosis despite supplemental oxygen
- Increased effort for little oxygenation (gasping, head bobbing, seesaw (pyridoxal) breathing, stridor)
- Desaturation (very concerning)
- Sleepiness (very concerning)
Cardiorespiratory Failure
This is a pre-arrest state that only lasts minutes before cardiovascular arrest
Signs
- Decrease in respiratory effort
- Cyanosis
- Bradycardia
- Unresponsiveness
Shock
- Inadequate delivery of oxygenated blood to tissue to meet metabolic demands
Minimum Systolic Pressure - 70 mmHg + Child’s age in years times 2
- Below this is considered hypotension
3 Types of Shock
Hypovolemic - Low cardiac output due to low preload
- Compensated with increased HR and increased SVR to maintain blood pressure
- Caused by severe fluid loss (gastroenteritis and hemorrhage)
Distributive - Low SVR and Low Preload
- Compensated with Tachycardia
- Caused by sepsis and anaphylaxis
Cardiogenic Shock - Low contractility
- Compensated with tachycardia and vasoconstriction (increased SVR)
- Causes - Myocarditis and Cardiac Arrest
Signs of Increased SVR
- Cool extremities
- Delayed capillary refill
- Diminished peripheral pulses
- Organ dysfunction (mental status, decreased urine output)
- Tachypnea (due to compensating for metabolic acidosis)
LATE SIGNS
- Hypotension
Septic Shock (Warm Shock)
- Low SVR and Tachycardia
- Patient will have warm skin instead of cool skin, strong bounding pulses, brisk capillary refill because there is vasodilation.
- The issue is too much blood is going to peripherals and not enough to organs.
- Hypotension is an early sign of Septic Shock
Compensated Shock -> Decompensated Shock -> Cardiorespiratory Failure -> Cardiac Arrest
