Newman Flashcards
Respiratorty distress in children
Ok
Most emergencies in kids
Are respiratory
Untreated respiratory distress
Cardiac arrest, cardiopulmonary failure
So want to intervene before it gets to that point
-bag or intubate
Cardiac arrest in kids
Usually due to progressive respiratory failrue->bradycardia, hypotension, cardiac arrest
What caues cardiopulm arrest in kids
Respiratory failure, cardiac failure, trauma, infection blah blah
At door what see
Appearance, breathing, circulation
The pediatric triangle
Flaring, gasping, dyspnea, pale, cyanotic, mottling pale, doesn’t always mean poor circulation, can be cold)
Nostrils flare indication of respiratory distress
Somnolent, lethargic, not moving, not interacting
Severe hypoxia, hypercarbia, Andorra respiratory fatigue
If haven’t intervened and HR goes down
Dwindle
If incosable by mom or nurse or if kid don’t want to be touched
Bad sign
Take note of all the info before you
Examine
Kid grunt
Effort to keep airway open longer
RSV season
Progressive-closing glottis to keep airway open
Slow, irregular respiratory pattern int he setting of respiratory distress is
Ominous sign
Body position in respiratory distress
Lean forward try to expand intrathoracici volume
Stridor
Croup, foreign body, inspiratory Barky cough
Narrow larynx or trachea
Wheezing
Squeaking noise by air in narrow tracheobronchial airway
Rales
Crackles, air passing through narrowed bronchi
-air through fluid, pneumonia
HR changes
Up with respi compromise then lose ability to compensate(hypoxia sets in) get bradycardia
Always O2 sat
Normal O2 sat
95 or higher
Hypercarbia
In resp distress co2 goes up, pH goes down , acidic , body hates this
Severely upper airway obstruction
Foreign body-doodling cant cough
Angioedema, epiglottis
Tension pneumothorax
Intervening can be lifesaving
Causes shift of mediastinal to side away from air leak, compresses the heart and good lunge
Can’t see lung markings
Signs of tension pneumothorax
Heart drop, sat droppping , respiratory distress
Put needle in and swoooooosh
Cardiac tamponade
Blood, serous fluid, air fill pericardial sack with life threatening compromise of venous return and cardiac stroke volume
Lupus with pericarditis, post op
Rare in kids
Becks triad of cardiac tamponade
Jugular venous distention, muffled cardiac sounds, hypotension (1/3 with cardiac tamponade)
Reropharyngeal and peritonsillar abscess
Sore throat, difficulty swallowing and oral pain, swelling
Hoarse voice
Can obstruct airway
Base of uvula shifted away from inflammation think peritonsilar absence
Retropharyngeal-of pharynx pushed up towards you
Croup
Acute laryngotracheobronchitis
Most common cause of infectious airway obstruction in kids 6 -36 months
Usually parainfluenza virus, or allergiv(less common)tracheitis is most often a secondary bacterial infection to croup kids
STRIDOR-CROUP
October to March
Vocal cord
Bronchiolitis
RSV
Wheeze
Less than 2
No treat-just supportive can wheeze forever
Mycoplasma viral
Can cause lobar pneumia and pleural effusions
Asthma
Inflammation, edema, bronchospasm, mucus
Triggers: infection, exercise, environmental irritants, stress GERD
Sudden worsening
Sudden changes can be due toalveolar disease and/atelectasis
Highest risk group for asthma for sudden death from asthma
Adolescence-teens , they don’t want to carrry medicine
Bronchioles
Asthma
Asthma cxr
Perihilar junkiness , bronchioles, rest of lungs kind of streaky,
CXR asthma attack
Lung expansion bilateral flattening of diaphragm
What most commonly causes anaphylaxis in kids
Food or meds
Life threatening, lips tingle, throat close,
*epinephrine !!!!!!!!!!!!!! Drug of choice
Foreign body resp distress
Sudden dramatic choking
Trachea body
Coughing, choking when FB is first ingested
Stridor, drooling choking if upper airway obstructed
Past carina where is foreign body
Right mainstem bronchus
Lower foreign body-cough, choking with first ingested
Delayed symptoms..recurrent pneumonia, chronic cough
Esophagus foreign body
Drooling swallowing problems
40% foreign bodies
No one knows there, no one saw it
Age group at risk for foreign body aspiration
1.5-3
Choking hazard
Button batteries if into trachea or esophagus within four hours corrode the mucosa and get tracheoesophageal fistula
How get foreign body out of trachea
Bronchoscopy
What happens when something gets in right mainstem bronchus
Ballvalve, air trapped, inspiratory and expiratory film can see!!!!!!
Put it together with ingestion and think right mainstem bronchus
Congenital or acquired CNS disesase
Neuromuscular delay-respiratory distress usually from chronic hypoventilation, infectious, trauma, medication, cerebral palsy
Reckless cell disease
Acute chest syndome-> sudden onset respiratory distress and chest pain, new infiltrates on cxr, fever
Sickle cell
If see kid with new infiltrate on x ray and have fever and resp distress think acute chest syndrome……..ACUTE CHEST SYNDROME
Hostpital antibiotics, oxygen, and pain control
Asthma is ___
Reversible
Diagnose asthma
Reversibility either spontaneously or with bronchodilator therapy
Limitation of airflow on pulmonary function testing or positive broncho-privation challenge
-methacholine challenge
Cough at night, cough exercising-make sure bronchospasm is part of differential
Asthma
Tightening smooth muscle that lines airway
Obstruction/inflammation
Mucus plugs
Exposure to allergen with asthma
Triggers it!! Mast cells are involved-mast cells produce leukotrienes (smooth msucle constrictors)
Leukotriene
Smooth msucle constrictor
If lot of allergies
Eosinophil up
Asthma path in prolonged status asthmaticus
Curshmann spirals and Charcot laymen crystals
Airway remodel asthma
Then airway, fibrosis, hypertrophy, may contribute to irreversible
Atopy FAMILY HISTORY so important
Strongest predisposing factory
Exposure to inhaled allergens
- dust mites
- cockroaches
- seasonal polllen
Asthma and family history
YES very likely
Copd vs asthma with tratment
Fev1 FEV1/FVC return with therapy
NO with cops
Asthma it can
Copd airflow limitation
Partially reversible
Asthma airflow lmitation
Reversible
Asthma key indicators cough
Worse at night, exercising-bronchospasm
Usually early in life
Asthma vs copd age of presentation
Kid asthma
Copd older
Obstructive spirometers
Swooping, see screen shot
Give b2 agonist improved rule
Prolonged inspiratory phase
Vocal cord dysfunction
Truncated inspiratory loop
Get abnormal closure of vocal cords, usually on inspiration, exercise triggers,
Treating for asthma and nothing work, flattened inspiratory flow
Sound like asthma look like asthma
Do spiroemtry, and get truncated inspiratory loop vocal cord dysfunction treated with behavioral techniques
Obstructive vs restrictive spirometry
See screen shot
Treat asthma
SABA sort acting beta 2 agonist
-albuterol, levabuterol
Relaxes smooth msucles, airway open,
Steroids for asthma
Cut down inflammation
What is your rescue medicine for asthma
B2 agonist
Long term treat asthma
Inhaled corticosteroids
Leukotriene modifiers
If need albuterol more than 2 x a week
ICS sometimes LABA-but not to be used alone use after try ICS or in conjunction,
Leukotriene modifiers
Released by mast cells
Lukasts and leukotriene receptor antagonists
Signs and symptoms of child in impending respiratory failure/arrest
Breathlessness, cant talk bc breathing so hard, not crying not making noise, seem drowsy, RR>30, unable to recline, use of accessory muscles, abdomen goes up when breath out PARADOXICAL MOVEMENT
Right before cardiac arrest have baby with alt hese signs HR up at first, in resp distress then go down as tire
HR down-really close to arresting
Most arrest of kids
Respiratory
Goal of verge of cardiac arrest or failure
Stabilize respiration
Intermittent asthma
<2 days/week symptoms
Nighttime awakening<2x a month
Use albuterol <3 days a week (or equal)
No interference in normal activity
Normal spirometry
When someone goes to persistent to intermittent
When not intermittent
Risk asthma severity
How many times in last year have had exacerbation that required oral or iv corticosteroids
1 and symptoms less than 2
Intermittent
If hospital 2 or more times and need steroids
Persistent category
Ass soon as one impairment markers is hit
Persistent and need long term controller
Initial treatment
SABA
Wheeze
Can be asthma can be other
Educate parents on asthma
Yes please
If on ICS
You are persistent
Acute exacerbation treat
O2
SABA
Oral steroid-if asthma attack that haven’t been able to pop out of with albuterol at home
If choking 2 yo
Think foreign body do x ray
14 yo girl high achiever athlete, cant breath when run not responding to asthma treatment
Vocal cord dysfunction
Kid with no thromboembolism except exercise
Recommend Saba before exercise
-if use before every time still intermittent asthma
5 yo new diagnosis of asthma can give all prescriptions and parents hesitant about ICS
Need to educate about side effects less effects than other
ICS risk
Thrush, rinse mouth out with water after you use it
Salty skin
CF
CF who is it high in
Ashkan AZt jews
CF
AR
CFTR encodes a chloride channel in epithelial cells on mucosal surfaces
Long arm chromosome 7
Most common mutation 3 nucleotides
Exocrine gland function
CF resp
Thick mucous in lung, chronic infections, colonized with bacteria
Ethnic distribution CF
Askanazi Jew 1/24
Inheritance CF
AR
Dad and mom carrier what percentage of kids will have no disease or no carrier
25%
50% carriers
25% have it
What happen with bad gene
Decreased Cl secretions
Increased reabsorption of Na and water , less water in mucus thicker
Does cf present same way in everyone
Poor penetrance NO
Env causes of CF
May effect penetrance
Most commmon presentation CF
Chronic and progressive lung disease
Exocrine pancreatic insuffiency
Why doesn’t CF present same
Modifier genes, env factors, nutrition
When most commonly see intestinal blockage
In nursery…muconium ileus
Clincial presentation baby
Lungs normal just after birth
a repeating cycle of infection and neutrophilic inflammation
-staph aureus and nontrpable HI
-pseudomonas aeruginosa is usually isolated from the respiratory sectretions
-not good
So usually meconium ileus is when suspect
New born screens-screens for sickle cell, CF, …
CF
Pseudomonas
Presence of bacteria in secretions for so long is ___ but as get older it is _____
Aureus younger
Pseudomonas eventually
Lung __ inflated with CF
Hyper
Air trapping and lungs big and diaphragma flat
Spirometry exhalation Curve in obstructive
Scoop
Most common cause of death CF
Respiratory death
Cf x ray
Expanded lung field flattened diaphragm, hazy and junky
Junk in upper lobes more
Hyperaeration in submediastinal area
Clubbing with cf
Ya
GI
Neonatal in nursery meconium ileus-not pooping when 36 hours old
Do newborn screen
If no poop 36-48 hours
CF, hershprungs
Older more stools
Malabsorption
Pancreas and CF
95% insuffiency
Pancreatic enzymes are prevented from reaching gut (reduced water content of secretions, precipitation of proteins, plugging of ductules and acini_
=fat soluble vit ADEK
-malabsorption of fat-steatorhea
Carb, protein
Failrue to thrive, foul smelling poop
History of jaundice or GI tract bleeding as a result of hepatobiliary involvement
What supplene ta CF patient
ADEK
Liver
Jaundice ductules plugged
Diabetes
8-12% get
Anything with a duct
Can be effected by CF
Most men with CF
Azospermic secondary to agenesis of the vas deferens
CF what have more of
Prolapsed rectum,
NASAL POLYPS
Criteria for diagnosis CF
Positive new born screening test, next step…perform confirmatory test
Plus positive cl test of sweat
-have more Cl in sweat , more cl and na stays in ductal lumen
Positive newborn screen and elevated sweat chloridex2
CF
Test for immunoreactive trypsinogen
Elevated in kids with CF
——-this is the screening in all states
