general Flashcards
what is laboured breathing
abnormal respiration characterised by evidence of an increased effort to breathe , including the use of accessory muscles of respiration, stridor, grunting, nasal flaring
why is it easier to see inhalation of a foreign object in expiration
during inspiration the diameter of bronchi/bronchioles increases; during expiration the diameter decreases. for this reason, inhaled foreign bodies can cause a one way valve effect allowing air entry during inspiration but trapping it during expiration
in expiration will see:
- greater lung volume of the affected side
- no upward movement of the diaphragm
- movement of the mediastinum to the opposite side (because during respiration pressure in the affected side remains constant while on the other side decreases)
what are the clinical features of inhaled foreign body?
- sudden onset in previously well child
- observed coughing, choking, or gagging while eating or playing
- stridor (partial upper airway obstruction)
- silent chest, paradoxical breathing (complete upper airway obstruction)
- wheeze
- chest wall recessions
- reduced air entry in some or all of the affected side
- hypoxia, tachypnoea, cyanosis
- may be asymptomatic with no clinical signs
how do you manage foreign body aspiration in children?
if upper airway FB:
- encourage cough
- 5 back blows followed by 5 thrusts
- if unconscious give 5 breaths then start CPR
if lower airway FB:
- treatment should be supportive with supplemental O2 and referral to paediatric bronchoscopist
what are the complications of FB aspiration?
- pneumonia
- bronchiectasis if chronic or recurrent infection (FB undetected and chronic)
- tracheitis
- lobar collapse/atelectasis
what is croup?
upper airway disorder common amongst infants and children, with peak incidence in age range 6months - 3yrs. most commonly caused by parainfluenza viruses
typically presents with:
- difficulty in breathing
- inspiratory stridor
- ‘seal-like’ barking cough
- hoarse voice
- low grade pyrexia (up to 38.5C)
- often preceded. by viral upper respiratory tract symptoms e.g. coryza
what are the airway symptoms caused by in croup?
caused by inflammation at the supraglottic and tracheal level causing airway narrowing and turbulent airflow (stridor)
list 3 differentials for croup
- epiglottitis
- bacterial tracheitis
- foreign body aspiration
how is croup managed
keep the child calm
mild:
- respond well to single dose steroid therapy (oral dexamethasone 0.15mg/kg/dose)
moderate/severe:
- biphasic stridor, irritability or reduced conscious lever
- may require nebuliser adrenaline and admission
what questions would you ask in an emergency Hx taking to a parent who’s child is having breathing difficulties?
- name/ age of child
- delivery term? how was the delivery? any complications?
- is the child on any medication?
- any previous breathing difficulties/ episodes like this in the past?
- any allergies?
- are immunisations up-to-date?
- what’s been happening e.g. onset/duration/anything make it worse or better?
- eating? drinking?
- could they possibly swallowed anything?
- any recent coughs/ colds/ symptoms?
if a child was drooling and quiet what particular condition would you be worried about? what is the causative organism and when should they be vaccinated against it?
epiglottitis
heamophilus influenza tube B vaccine at 8weeks, 12weeks and 16weeks as part of 6-in-1 vaccine
a) what is the like diagnosis:
Pcx: 3y/o boy with breathing difficulties, breathing noisily, barking cough, worse at night, still able to eat and drink, distressed/crying, temp of 38.5C, pure of 135bpm, cap refill <2sec, O2 sats of 95% on room air and RR of 40per min?
b) if the child was well, had no fever, and suddenly started breathing with stridor and coughing a lot, possibly with some respiratory distress, what might the cause be?
a) croup
(parainfluenza virus. common in 6months - 3 years)
b) foreign body aspiration
how do you assess the severity of croup?
assess intercostal recession, air entry on auscultation, degree of cyanosis and level of consciousness at rest and if agitated/distressed
what tool would you use to call in ahead to paediatric registrar when admitting child with suspected severe croup?
SBAR
situation:
- who are you?
- what are you doing?
- what would you like to do?
- anything very important to the current situation?
background
- Childs age
- background health
- other relevant background information e.g. social
- Hx of tonights presentation
assessment
- on examination… e.g. distresses/unwell/very unwell etc
- relevant findings/negative findings
- changes in presentation
recommendation
- treatment so far
- need for admission and why
- how the pt will be getting to hospital and timing of this
*other tools = ATMIST (useful in trauma when handing over to ambulance/ED), METHANE (for handing over to a control service e.g. ambulance control), AMPLE (key questions in an emergency history taking situation)
consider some types of unconscious bias present in medicine
- anchoring bias - holding on to the 1st diagnosis; some one has written ‘asthma; in the notes, all further presentations with breathing difficulties are attributed to this
- optimism bias - at the end of the shift - you are desperate to get home - yo convince yourself to think that the child’s croup is probably ‘not that bad’ and it will be OK as long as you give a strong worsening statement
- confirmation bias - we only pay attention to results that confirm our preconception; e.g. the sats are normal, you use this to ‘confirm’ that the pt can have severe croup (disregarding other results)
- over-confidence bias - we are overconfident in our ability to manage a situation (think about the ‘unknown unknowns’)
