ASA Refresher Course Lecture Common Pediatric Emergencies · 2016. 2. 9. · ASA Refresher Course Lecture Common Pediatric Emergencies Randall Flick, MD, MPH. Mayo Clinic ©2011 MFMER

ASA Refresher Course LectureCommon Pediatric Emergencies

Randall Flick, MD, MPHMayo Clinic

©2011 MFMER | slide-1

No Disclosures!All Patients Pictured have provided consent for the use of the images

How many of you were here for this RCL last year?


Common things are common

• Pediatric emergencies can occur in any setting.

• I have chosen a few cases that I think will be informative regardless of your practice.

• Lets try to get through all/some of them


FiveEmergency Pediatric Cases

Toddler w/ Suspected Aero-Esophageal Foreign Body.

The School Age Child with a Bleeding Tonsil, OSA & ...

Laryngospasm at emergenceNewborn with progressive respiratory distress

and more if we have time!


http://files.myopera.com/prateeknayak/blog/tonsils%20Dr%20Prateek%20Nayak,ENT%20Doctor%20Bangalore,ENT%20Specialist%20Bangalore.jpg

http://upload.wikimedia.org/wikipedia/commons/thumb/3/38/HumanNewborn.JPG/250px-HumanNewborn.JPG

3 y.o. with Sleep Disordered Breathing s/p Tonsillectomy

• Uneventful outpatient adeno-tonsillectomy.

• Home 4 hrs in PACU.

• Put to bed at 8 pm

• Dad checks on the child• Blood on the pillow• Immediately brought to the ED

• In ED• Awake, alert, crying• P 132 BP 82/44 R 30


http://files.myopera.com/prateeknayak/blog/tonsils%20Dr%20Prateek%20Nayak,ENT%20Doctor%20Bangalore,ENT%20Specialist%20Bangalore.jpg

Post-Tonsillectomy Bleeding• 2 peaks

• Early <24 hrs (primary)• Late > 1 day (secondary)

• Mortality assoc. w/ primary bleeding.• Loss of the airway• Vomiting & aspiration• Exsanguinating hemorrhage• Neurologic (carotid) injury

• Bleed rate • < 1% primary • ~3-5% secondary

• Mortality rate 1:10,000-35,000


• 475 operative bleeding events among 16596 cases (2.9%)• Rapid sequence induction 84% (MRSI 5%)• Succinylcholine 88%• 3 patients required transfusion (<1%)• Hypoxemia 9.9%• Bradycardia 4.2%• 2.7% Difficult airway• No major morbidity or mortality



Does Use of dexamethasone increase risk of bleeding?


My Approach1. IV placement, hemoglobin, coag’s &

T&S.

2. Preoperative Hydration ~ 20 cc/kg (LR/Saline)

3. Sedation with midazolam when separating from parents?

4. Begin induction sitting if actively bleeding.

5. MRSI with ketamine/propofol/succinylcholine

6. Small cuffed ETT (round down)

7. Extubate Deep ?

Which I did not do in this case…

Laryngospasm!!


Laryngospasm• Forceful and sustained

adduction of the true and false vocal cords.

• Complete v. incomplete

• Inspiratory stridor v. no air movement


Fig. 1. Prevention of laryngospasm. URI = upper respiratory tract infection.

Copyright © 2012 Anesthesiology. Published by Lippincott Williams & Wilkins. 12


Fig. 2

Fig. 2. Treatment of laryngospasm. CPAP = continuous positive airway pressure; FiO2 = fractional inspired oxygen tension; IM = intramuscular; PACU = postanesthesia care unit. Adapted from Hampson-Evans D, Morgan P, Farrar M: Pediatric laryngospasm. Paediatr Anaesth 2008; 18:303–7. Used with permission of John Wiley and Sons.

Copyright © 2012 Anesthesiology. Published by Lippincott Williams & Wilkins. 13

Case Scenario: Perianesthetic Management of Laryngospasm in Children

Orliaguet, Gilles A.; Gall, Olivier; Savoldelli, Georges L.; Couloigner, Vincent

Anesthesiology. 116(2):458-471, February 2012.

doi: 10.1097/ALN.0b013e318242aae9

Laryngospasm


http://journals.lww.com/anesthesiology/Fulltext/2012/02000/Case_Scenario___Perianesthetic_Management_of.32.aspx

Given the history of OSA you are asked for advice on post-op pain management.

• Children with OSA are at greater risk for airway obstruction immediately after T&A.

• Young(2 or 3 yrs), airway abnormality, syndromic…(Schwengel 2009)

• Children with OSA have heightened sensitivity to opiates. (Brown et. al Anesthesiology 2006)

• Codeine is a bad drug: don’t use it. (Warning from US FDA 2012)

• More malpractice claims in children v. adults (Morris et. al, 2008)


HistoryDoes your child snore?

Does he or she stop breathing?Does he or she run, play and keep up w/ other kids of the same age?

PhysicalChromosomal abnormality

ObesityGrowth failure

Airway anomalyHypotoniaASA PS III


Children with OSA are more sensitive to narcotics.The more severe the OSA the more sensitive.


Codeine has been associated with several deaths in young children

• Ultra – rapid metabolizers (CYP 2D6)• Codeine - Morphine• 1-7% population• 25- 30% African/Ethiopian

• Typical doses may produce toxicity

• Most reports in kids after T & A

• May also affect nursing infants

• Poor metabolizers get little pain relief

• There are better drugs

• We are in the process of eliminating codeine as an option for young children.


Average Malpractice Claim $403,000 Settled and Trial

Claims against anesthesiologists higher & more frequent. Trial awards 5 million v. 839 K (surgeons)



Called to the ED to Pre-op a child with a Suspected Aero-Esophageal Foreign Body.

• 15 m.o. with episode of coughing/choking 1 day ago now drooling and refuses to eat.

• Fever now 38.4

• Nurse describes wheezing but you hear normal breath sounds.

• Mild retractions, agitated, difficult to examine.

• SaO2 95%

You agree that the child has probably ingested a F.B.


The moonlighter in the ER is sure it is in the trachea and would like to go directly to the OR.You are skeptical because…

• Absence of severe respiratory distress, stridor, or wheezing make it unlikely to be in the trachea.

• Drooling & refusal to eat are typical for esophageal F.B.

• It happened yesterday.

• Lets slow down and get an x-ray because you know that• > 80% of tracheal F.B. are organic material (nuts).• > 80% of aspirated F.B. are lodged in the bronchi.• The chest x-ray is normal in less than 20%

A CXR probably will not tell you it is an airway FB but it may tell you that it is not


I love my job so I make a game out of it. Before you look at the x-ray I try to guess…

1. What the F.B. is

2. Where exactly it is located

What are your guesses?


Esophageal Foreign bodies• Most are Esophageal (tracheal rare)

• Most are Coins (70%)

• Most are at the Cricophayngeus (~50%)• Thoracic inlet ~20% • Aortic Arch ~ 20%• Lower ~ 10%

• 3 Primary Methods of Removal• Endoscopy• Radiology (Foley Catheter)• Bougienage

Does it Matter to You?©2011 MFMER | slide-23

ManagementWhat if…• The coin is in the stomach?

• Leave it alone• The coin is in the esophagus and there are no

symptoms?• Leave it alone…until the light of day.

• 30% will pass into the stomach(14 – 43 –67% based on location)

• If it going to pass it will pass by 19 hrs.

• The coin is seen on edge in A-P film?• Get a (or look at the) lateral film

• Most are still in the esophagus.©2011 MFMER | slide-24

Tracheal air column anterior

Is this a coin?


Can you differentiate a button battery?

Could this be a button battery?

It is clearly a coin. Actually 3 - Now what?©2011 MFMER | slide-26

American Bronchoesophagological Association2006 Presidential Citation for Foreign Body ManagementManagement of a Catastrophic Aerodigestive Foreign Body

Thomas Andrews, MD, FACS*, James Quintessenza, MD, Jeffrey Jacobs, MD, FACS., Richard Harmel, MD, FACS

The patient, A.P, a nine-month-old, was brought to the operating room urgently from the emergency center. The patient could not be adequately ventilated except with a 4.5 cuffed endotracheal tube with external pressure held at the neck to prevent air escape through the esophagus. The patient's history was significant for a foreign body ingestion of a camera battery which was removed three days prior to presentation. At the time of removal the battery was grasped with a basket through flexible esophagoscopy and removed, according to history, without difficulty; however, there was note of erosive esophagitis at the site. Upon presentation, ventilation was difficult through the existing endotracheal tube and the saturations could only be held in the 80s despite intubation. Because the patient had previously placed IV access, the endotracheal tube was removed and the patient was intubated with a ventilating 3.5 bronchoscope. The examination revealed no supraglottic or glottic abnormality; however, the distal trachea demonstrated a large posterior defect with only a small strand of tissue connecting the distal trachea with the carina. Copious secretions were present in the left bronchus and the right mainstem, when selectively cannulated with the ventilating bronchoscope, could not hold saturations above 80.

We then selectively intubated the right mainstem bronchus with a 3.5 cuffed endotracheal tube over a Storz-Hopkins telescope. Selective intubation on the left was problematic due to copious secretions. However, even with selective intubation on the right, saturations did not rise above 80, and in many instances were down to a low of 47.

The pediatric cardiothoracic service was then called for consideration of emergency cardiopulmonary bypass. The cardiothoracic surgeons placed the patient on cardiopulmonary bypass via a right neck cannulation and the patient was stabilized. Via a right thoracotomy, a large defect in the posterior wall of the trachea distally was demonstrated as well as complete erosion of the esophagus at the same level. Severe mediastinitis including a large abscess was found at the site. The proximal and distal segments of the esophagus were ligated. The posterior tracheal wall was then repaired with a pedicled intercostal muscle flap.

During this, the patient had central lines placed; multiple thoracostomy tubes inserted and a proximal esophageal sump with a decompressive gastrostomy tube were completed. Three days later, the patient underwent bronchoscopy which revealed some dehiscence of the flap. Conservative therapy was initially attempted.

Ten days following the initial procedure, the patient returned with dehiscence of the initial tracheal reconstruction and underwent tracheal resection with end-to-end anastomosis of the intrathoracic trachea and a small resection of distal necrotic tracheal tissue while on cardiopulmonary bypass. The repair was done using an esophageal patch tracheoplasty.

As expected, the patient had significant problems with mediastinitis initially, but the symptoms resolved over the next two weeks. After the second repair of the tracheal injury was completed, the patient underwent a cervical esophagostomy and resection of a blind-ending proximal esophagus.

The patient has continued to do well, was discharged from the hospital and although reconstruction of the esophagus will take place at a later time, the patient has continued to have normal activity without airway symptoms. Follow-up bronchoscopy reveals redundant tissue at the repair site that looks obstructive but has not accompanying symptoms.

This potentially fatal presentation was only averted due to the multidisciplinary work of Pediatric Cardiothoracic Surgery, Pediatric Surgery, Pediatric Anesthesia, Pediatric Intensive Care and Pediatric Otolaryngology. From: The Department of Otolaryngology & Pediatrics, University of South Florida and Pediatric Otolaryngology, All Children's Hospital*; The Congenital Heart Institute of Florida, University of South Florida and Division of Cardiothoracic Surgery, All Children's HospitalÝ; The Department of Surgery, Division of General Surgery, All Children's Hospital_ St. Petersburg, Florida

http://vimeo.com/38698808 ©2011 MFMER | slide-27

http://vimeo.com/38698808

When should you remove an Esophageal F.B.?

About 30% will pass spontaneously70% if distalMiddle or Distal = Observe for 12-18 hrs


Because it is proximal and has been present for almost a day, you and your colleagues determine that it must come out tonight…

The preferred method of removal is?

1. Balloon tipped catheter (Foley)

2. Bougienage to push into the stomach

3. Rigid endoscopy

4. Flexible endoscopy

5. Other?All Strategies work in more than 98% of patients


Are Costs & Complication Rates Similar?Endoscopic removal is > 4x the cost of other methods


How about metal detectors?


Things to rememberIf you must go to the operating room

• If asymptomatic or mild sx admit and wait for the child to be NPO.

• Sedate if possible (IV, oral?, nasal, rectal)

• Inhalation (oxygen and sevoflurane) or intravenous induction.

• Consider IV induction if proximal

• I prefer deep w/ sevo/oxygen spontaneous breathing

• Be prepared to remove FB with a Magill or bronchoscopic forceps.


Success!!!


Called to the D.R. to assist with NEONATE WITH NECK MASS & DISTRESS

• 4200 gms• P,L,&D UNCOMP.• APGARS 8 & 9• RESP DISTRESS• NECK MASS• ERBS PALSY• FAILED INTUBATION


NEONATE WITH RESPIRATORY DISTRESS

• NECK MASS• SEVERAL ATTEMPTS TO INTUBATE• UNABLE TO VENTILATE• PNEUMOTHORAX• DESAT - BRADYCARDIA - ARREST• UNABLE TO RESUSCITATE• PATHOLOGY - NO MASS



TRACHEAL RUPTURE

• EXPANDING NECK MASS• NONE AT AUTOPSY (AIR v. FLUID)• SHOULDER DYSTOCIA • ERBS PALSY• SUB-Q EMPHYSEMA/PNEUMO

TRAUMATIC TRACHEAL RUPTURE1) UMANS-ECKENHAUSEN, EUROPEAN J. PEDIATRICS 19972) DE LAGAUSIA, EUR. J. PED SURG. 1991


5 y.o. Motor Vehicle Crash • Previously Healthy

• Unrestrained

• Intubated after several attempts in the field

• On Arrival in the ED• Arousable to pain GCS 8-9• Hypotension/Tachycardia• SpO2 80’s• T 35.4• IV access lost in transport


You are called to expect emergent transfer to the OR. So you wander up to the in the ED

• Persistant hypoxia (SpO2 80-90%)

• Hemothorax is diagnosed• Chest tube is placed

emergently.• No improvement• Ruptured diaphragm is

diagnosed• The child is emergently

brought to the OR


1.Review the films 2.You pull back the

ETT & ask the surgeon to kindly pull back the chest tube.

3.You also pull back the OG tube and place a CVL.

You know that all tubes/lines are always in too far in pediatrics so you…


What to expect when caring for a pediatric patient in the ED.• Mainstem intubation

• Too small un-cuffed ETT

• Tiny IV with Mini-drip tubing

• CVL - too deep

• Ventilation• Too big • Too fast• Too high

• Poorly fitting or no C-collar

• Cold patient


Field Airway Management

• Cooper 2001• BVM (479) v. Endotracheal Intubation (99)• Mortality 48% both groups

• Gausche 2000• 830 children (<12 yrs)• Randomized (odd v. even days) ETT v. BVM• No difference in mortality or neurologic outcome• Longer scene time with ETT• 6.7% ETT dislodged w/o recognition

Rapid transport is probably better


Appropriateness of endotracheal tube size and insertion depth in children undergoing air medical transport orf et. al Pediatric Emergency Care V. 16(5) oct 2000

• 216 pts < 14

• Field ETI

• Appropriate size/depth

• Results• 83% +- .5 size

• 91% too small• 43% appropriate depth

• 96% too deep


What about the C-SpineCervical Spine Injury in Children

• C-spine injury in less common in children

• 18 per million• 1100 cases in the U.S. per

year

• 70% above C4 – frequently fatal• Younger = higher (0-2 yrs C1,

C2)

• SCIWORA 25 – 60%

• Adult injury patterns at age 10 –12 years Pseudo-subluxation


SCIWORASpinal Cord Injury Without Radiographic Abnormality

• Up to 2/3 of all c-spine injuries in children under age 8 have no radiographic abnormality.

• Mechanisms• Vascular injury with extreme flex – ext.• Subluxation – injury – spont. reduction.

• Management• Maintain immobilization• Flexion – extension views may be normal• MRI

Maintain Cervical Stabilization until cleared by exam & MRI/flexion –extension views


Pediatric Emergencies: You too can do it!!!

Thanks for listeningI Will leave you with this…



STRIDOR IN AN 11 Y.O.

• PROGRESSIVE STRIDOR

• BIPHASIC• ORTHOPNEA• CERVICAL

ADENOPATHY• COUGH



ANTERIOR MEDIASTINAL MASS

• AIRWAY/VASCULAR COMPRESSION• SUDDEN DEATH ON INDUCTION• TREAT BEFORE BX IF:

• SX (STRIDOR, DYSPNEA, ORTHOPNEA)• PEFR < 50%• TRACHEAL DIAMETER <50%

• TX RARELY AFFECTS DX.


CASE20 M.O. WITH STRIDOR• O/W HEALTHY• FEVER ( 39.8) FOR 36 hrs• CROUPY COUGH X 2 DAYS• PROGRESSIVE LETHARGY• WORSENING STRIDOR• IMMUNIZATION U.T.D.


MOST LIKELY DIAGNOSIS?

1) CROUP

2) EPIGLOTTITIS

3) BACTERIAL TRACHEITIS

4) PERI-TONSILLAR ABCESS



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ASA Refresher Course Lecture Common Pediatric Emergencies · 2016. 2. 9. · ASA Refresher Course Lecture Common Pediatric Emergencies Randall Flick, MD, MPH. Mayo Clinic ©2011 MFMER