EMS Protocol of the Week!!! - Stridor/croup/epiglottitis (Peds)

It’s that time of year! All the children have been coming in with respiratory distress. These days, most often it’s a child with bronchiolitis. But it’s also important not to forget about the kids coming in with croup, anaphylaxis, airway obstruction, and the rare but scary epiglottitis.

Management?

As always…ABC’s.

1.     Administer high flow O2 via NC or face mask

2.     Consider obstructed airway vs. anaphylaxis as causes of respiratory distress

3.     Stridor at rest? Think croup.

a.     Epi 3mg nebulized OR racemic epi nebulized

4.     Get IV access (in real life, depending on age of the child I feel like this doesn’t always happen, but it’s important for children in respiratory distress who can decompensate quickly)

5.     STEROIDS!! (ONLY if 2 years or older)

a.     Dex 0.6mg/kg to max of 12mg or methylpred 1mg/kg to max of 60mg

If EMS suspects Epiglottitis, EMS will NOT attempt advanced airway – will only ventilate with bag valve mask and transport ASAP

Last but not least, OLMC (which we are all experts on now after Vic’s great emails the other week)

-       EMS must call if kid is <2 y/o in respiratory distress and wants to give steroids

KEY POINTS:

-       Croup = stridor + retractions + barking cough

-       Epiglottitis = stridor + retractions + muffled voice + high fever (TOXIC APPEARING)

-       Unvaccinated = high risk for epiglottitis

-       Airway obstruction (foreign body, mass) = biphasic stridor

-       Don’t agitate a child already in respiratory distress

-       Dex > methylpred in kids

And if you want more... www.nycremsco.org

Jennifer Wolin, MD

Emergency Medicine PGY-2 Resident Physician

Maimonides Medical Center

Intubating Asthmatic Patients

Asthma is Greek for panting, which is a fitting translation for a patient that presents with a severe asthma exacerbation. We try to avoid intubating these patients because they are prone to compilations such as pneumothorax, mucus plugging, and increased morbidity and mortality. 

However, there are specific situations when you may consider intubating an asthmatic patient. One reason is that your patient may not be improving despite maximal medical therapy, such as BIPAP, albuterol, ipratropium, magnesium, epinephrine/terbutaline, ketamine, etc. Another reason is that your patient may now be altered, and have worsening work of breathing, and vital sign abnormalities. Remember that a “silent chest” is a poor prognostic indicator; you may not hear wheezing because they are not moving any air. 

If you choose to intubate, there are tricks to maximize your success and optimize your management of your patient on the vent. 

• Use a large ETT (8-9) because it reduces airflow resistance and can facilitate procedures later (such as bronchoscopy). 

• Ketamine is a useful induction agent because of its bronchodilatory effects. It may also be useful if you choose delayed sequence intubation. 

• High airway pressures can cause hypotension after intubation, so consider giving volume if there is a current or prior history of hypotension. 

• If hemodynamics are compromised consider giving an epinephrine drip. It is considered a systemic bronchodilator that can provide hemodynamic support as well as bronchodilation. 

• Keep a low respiratory rate when bagging or on the vent (6-8 breaths/min). Giving them time to exhale will decrease the chances of air trapping and pneumothorax. Another way to do this is to increase the I:E time (1:4 or 1:5). 

• If the vent is alarming, troubleshoot (DOPES mnemonic) but be suspicious for mucus plugs, pneumothorax, or breath stacking. If they are breath stacking, disconnect them from the vent and push on their chest to help them fully exhale.  

A quick note about auto-PEEP and breath stacking: Auto-PEEP refers to trapping gas in the lungs during respiration. This occurs when one breath can’t be fully exhaled before the next inhalation. This trapped gas causes additional positive pressure, known as “auto-PEEP” in the chest which is typically higher than the PEEP set on the ventilator. This process predisposes patients to develop a pneumothorox. 

Thanks for reading!

Ariella

EMS Protocol of the Week - Obstructed Airway (Adult and Pediatric)

The prehospital approach to the obstructed airway shows a nice progression of responsibilities based on level of training. CFRs at the most basic level will encourage coughing and other AHA-recommended choking maneuvers. BLS crews will request ALS backup, but if their expected arrival time is longer than the time it would take to transport to the hospital, they will transport the patient, again attempting to perform basic maneuvers to clear the airway.

If ALS providers are on scene, they will perform DL to attempt to manually remove the obstruction with Magill forceps; if unsuccessful, the subsequent steps walk through how to intentionally right mainstem the foreign body while obtaining an advanced airway.

Not a lot to do on the OLMC side other than to be aware of this stepwise progression, as well as have an understanding of pre-intubation sedation options if needed. What are those options? Stay tuned – the answer may…take your breath away?

www.nycremsco.org and the protocol binder for more!

Dave