PCTH - Croup/Bronchoconstriction Flashcards
What is croup?
- upper respiratory tract infection (usually viral)
- causes swelling of the throat (larynx, trachea)
- primarily in kids under 8
- when a cough forces air through the narrowed passageway, causes the “barking” sound similar to a seal
Croup Medical Directive
Indications
Conditions
Contraindications
Indications:
- Current history of URTI; AND
- Barking cough or recent history of a barking cough
Conditions:
* for epinephrine ⇒ Age ≥ 6 months to <8 years & HR <200 BPM & stridor at rest (i.e. only SEVERE croup; do not treat mild/mod croup w/ epi)
* for dexamethasone ⇒ Age ≥ 6 months to <8 years, unaltered LOA (bc PO route) & For mild, moderate and severe croup
Contraindications:
* Epinephrine: allergy or sensitivity to epinephrine
* Dexamethasone: allergy/sensitivity to steroids; steroids received within the last 48h (bc commonly used in in ED/HCP and has long duration of action); unable to tolerate oral medications
Croup Medical Directive
Treatment
Clinical Considerations
Treatment: consider epinephrine & dexamethasone (see screenshot)
Clinical Considerations: n/a
What shall you do for mild/mod croup patients?
- consider dexamethasone
- keep child calm
- move to cold environment
What is stridor?
loud & high pitched sound, usually heard on inspiration and generated by upper respiratory tract obstruction/narrowing (so will be louder over neck than chest wall)
note that there can be many causes to stridor so you need URTI hx & barking cough hx to think it’s infection-mediated laryngeal edema that’s causing the stridor in croup pts
Common causes of stridor
- croup (infection)
- FBAO
- anaphylaxis
- epiglottitis
- trauma, etc.
Under indications for the Croup Medical Directive, what is considered “current history of URTI”?
- elicit history from parents
- child complaining/presenting as sick, coughing (productive?), fever
- usually cool moist air (like during nighttime) would soothe cough so they may say it disappears and then comes back
As per the ALS PCS, what are the pediatric vitals (RR and HR) for the following?
0-3 months
3-6 months
6-12 months
1-3 years
6 years
10 years
0-3 months: RR 30-60, HR 90-180
3-6 months: RR 30-60. HR 80-160
6-12 months: RR 25-45, HR 80-140
1-3 years: RR 20-30, HR 75-130
6 years: RR 16-24. HR 70-110
10 years; RR 14-20, HR 60-90
What steps are taken to prepare pt for epinephrine administration under the Croup Medical Directive?
For the patient:
- place child in position of comfort (which is usually in parent’s lap)
- high flow O2 (via NRB however they may not tolerate mask so consider blow-by oxygen, have pt hold it near their face)
- nebulizer mask (place NEB mask also as close as possible as they also may not tolerate it)
For the drug:
- Check epi concentration (1mg/mL)
- open epi and draw up
- deliver
If the pt with croup is <1 y.o. and parents do not know their current weight, what can you do to determine how much epi to give?
use their last weigh-in weight at the doctor’s
What steps do you have to take when delivering epi to the croup pt?
1) add the required amount to the nebulizer
2) adjust the O2 flow rate to 6-8 LPM until you see a nice mist before you can deliver the epi (if you see fluid accumulation around the mask, your flow rate may be too high)
3) Replace NRB with nebulizer mask after medication has been delivered
How would croup patients typically be transported?
in pedimate!
Parameters for pedimate
10-40 lbs
4-18 kg
What other directives can croup pts be considered for?
bronchoconstriction (but only after epi because of upper airway compromise taking priority)
What is salbutamol?
- short acting β2-adrenergic receptor agonist
- used for relief of bronchospasm
- Therapeutic classifications: bronchodilator, anti-asthmatic
Bronchoconstriction Directive
Indications
Conditions
Contraindications
Indications: Respiratory distress AND suspected bronchoconstriction
Conditions:
- For salbutamol: N/A (no conditions)
-
For epinephrine:
- RR: BVM ventilation required (note that as long as a pt meets the need for BVM, this condition is fulfilled. i.e. you don’t actually have to be bagging the pt necessarily for them to meet this condition)
- Other: Hx of asthma
- For dexamethasone:
- Other: Hx of asthma OR COPD OR 20 pack-year hx of smoking (used to help quantify cumulative lung disease and assess risk)
Contraindications:
- For salbutamol: allergy or sensitivity to salbutamol
- For epinephrine: allergy or sensitivity to epinephrine
- For dexamethasone: allergy or sensitivity to steroids; currently on PO or parenteral (i.e. injectable) steroids (*because they’re already receiving the anti-inflammatory benefits from steroids and you don’t want to OD)
Bronchoconstriction Medical Directive
Treatment
Clinical Considerations
Treatment: see screenshot
- Consider salbutamol
- consider epinephrine
- consider dexamethasone
Clinical considerations:
- Epinephrine should be the 1st medication administered if the patient is apneic. Salbutamol MDI may be administered subsequently using a BVM MDI adapter.
- Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a declared febrile respiratory illness outbreak by the local medical officer of health.
- When administering salbutamol MDI, the rate of administration should be 100 mcg approximately every 4 breaths.
- A spacer should be used when administering salbutamol MDI.
