maryland pre-hospital protocol for croup maryland emsc program

Maryland Pre-hospital Maryland Pre-hospital ProtocolProtocol

for Croupfor Croup

Maryland EMSC Program

Care for Children with Croup

Developed byDeveloped by

Hopkins Outreach for Pediatric EducationHopkins Outreach for Pediatric Education

Written byWritten by Elizabeth Berg, RN, BSN, EMT-BElizabeth Berg, RN, BSN, EMT-B

Reviewed by Maryland PEMAG 7/2001Reviewed by Maryland PEMAG 7/2001

Objectives

Identify three signs and symptoms of croupIdentify three signs and symptoms of croup State the treatment protocol for croupState the treatment protocol for croup List two criteria for medical direction List two criteria for medical direction Identify three signs and symptoms of Identify three signs and symptoms of

pediatric respiratory failurepediatric respiratory failure List two criteria for BVM ventilationsList two criteria for BVM ventilations

Pediatric Medical Emergencies

Epidemiology of Croup

Common age range is 3 months to 4 yearsCommon age range is 3 months to 4 years Most severe symptoms under 3 yearsMost severe symptoms under 3 years More common in malesMore common in males Most common during the winter monthsMost common during the winter months Typical duration of illness is 5-6 daysTypical duration of illness is 5-6 days


Pathophysiology of Croup Viral infection of the vocal cordsViral infection of the vocal cords

– Parainfluenza virus (75%)Parainfluenza virus (75%)– AdenovirusAdenovirus– Respiratory syncytial virus (RSV)Respiratory syncytial virus (RSV)– InfluenzaInfluenza– MeaslesMeasles– Bacterial super infection Bacterial super infection


Pediatric Anatomical and Physiological Differences

Airway shape: cone versus cylindricalAirway shape: cone versus cylindrical Narrowest point at the cricoid ringNarrowest point at the cricoid ring Anterior vocal cordsAnterior vocal cords Tongue larger in proportion to the mouthTongue larger in proportion to the mouth


Airway Differences


Pediatric Anatomical and Physiological Differences

Smaller, more collapsible Smaller, more collapsible lower airwayslower airways

Diaphragm dependentDiaphragm dependent Poorly developed intercostal Poorly developed intercostal

and accessory musclesand accessory muscles


Clinical Presentation of Croup Signs and symptomsSigns and symptoms

– Loud barking coughLoud barking cough– HoarsenessHoarseness– Respiratory distressRespiratory distress

Nasal flaringNasal flaring RetractionsRetractions Head-bobbingHead-bobbing Inspiratory grunting or stridorInspiratory grunting or stridor


Clinical Presentation of Croup

Associated illnessesAssociated illnesses– Ear infectionEar infection– PneumoniaPneumonia


Neck X-rays

Normal Airway Narrowed Airway

Other Causes of Pediatric Airway Obstruction

Vascular RingVascular Ring Blood vessels compress the tracheaBlood vessels compress the trachea

TracheomalaciaTracheomalacia Softening of the tracheal wallSoftening of the tracheal wall

Foreign body Foreign body EpiglottitisEpiglottitis


Epiglottitis

Clinical presentationClinical presentation– Over 5 years of ageOver 5 years of age– Most common organism is Hemophilus influenzaMost common organism is Hemophilus influenza– Rapid onset of stridor and droolingRapid onset of stridor and drooling– Associated with high feverAssociated with high fever


Epiglottitis

InterventionsInterventions– High flow oxygenHigh flow oxygen– Calm environmentCalm environment– No manipulation of the upper airwayNo manipulation of the upper airway– Hospital notificationHospital notification– Do not initiate croup protocolDo not initiate croup protocol


EMS Protocol for Croup

Initiate General Patient CareInitiate General Patient Care– Allow children to assume their own position of Allow children to assume their own position of

comfortcomfort– Semi-fowler’s position will promote diaphragm Semi-fowler’s position will promote diaphragm

expansionexpansion– Allow parent to remain with child for emotional Allow parent to remain with child for emotional

supportsupport



Initiate General Patient CareInitiate General Patient Care– Get down to child’s levelGet down to child’s level– Use age-appropriate wordsUse age-appropriate words– Give them choices, when ableGive them choices, when able– If stable, allow the child to set the pace of the If stable, allow the child to set the pace of the

procedureprocedure



Initiate General Patient CareInitiate General Patient Care– Foster trust by telling the truthFoster trust by telling the truth– Be aware of the capabilities of the local EDBe aware of the capabilities of the local ED– Consider risks and benefits of transporting the Consider risks and benefits of transporting the

child to a pediatric referral centerchild to a pediatric referral center– Administer oxygen without increasing agitationAdminister oxygen without increasing agitation


Oxygen Administration in Children

Infants/toddlers may not tolerate a face maskInfants/toddlers may not tolerate a face mask– Have parent hold mask near patient’s faceHave parent hold mask near patient’s face– Place oxygen tubing set at 10 lpm in the bottom Place oxygen tubing set at 10 lpm in the bottom

of a paper cup with stickers insideof a paper cup with stickers inside– Use commercially designed teddy-bears with Use commercially designed teddy-bears with

oxygen port; may also use for nebsoxygen port; may also use for nebs



PresentationPresentation– Severe: Priority 1 Severe: Priority 1

Unable to speak or cryUnable to speak or cry Decreased LOCDecreased LOC Bradycardia or tachycardiaBradycardia or tachycardia Hypertension or hypotensionHypertension or hypotension



PresentationPresentation– Moderate: Priority 2Moderate: Priority 2

Slow onset of respiratory distressSlow onset of respiratory distress Barking coughBarking cough FeverFever Audible stridorAudible stridor



TreatmentTreatment– Perform initial patient assessmentPerform initial patient assessment

Patent airwayPatent airway Adequate respiratory effortAdequate respiratory effort

– Assign a treatment priorityAssign a treatment priority– If patient > 40 kg (88 lbs) treat under adult If patient > 40 kg (88 lbs) treat under adult

protocolprotocol


Continuum of Respiratory Failure

•Tachypnea•Nasal flaring•Pale•Stridor•Expiratory wheezing

•TachypneaRR > 60•Retractions, grunting

•Mottled•Head bobbing

•Insp/Exp wheezing

•Bradypnea•See saw respirations•Gray, cyanotic•No air movement•No wheezing



TreatmentTreatment– Place on cardiac monitor, pulse oximeterPlace on cardiac monitor, pulse oximeter– Record vital signsRecord vital signs– Initiate IV with LR at a KVO rateInitiate IV with LR at a KVO rate

Do not withhold epinephrine if IV not easily obtainableDo not withhold epinephrine if IV not easily obtainable Over 75% of croup cases seen in ED have no IVOver 75% of croup cases seen in ED have no IV If patient is unstable, establish IO access If patient is unstable, establish IO access



Under 40 kilograms with S/S of croupUnder 40 kilograms with S/S of croup– Administer 3 cc of NS via nebulizer for 3-5 minsAdminister 3 cc of NS via nebulizer for 3-5 mins

Continue NS nebulization during transport if improvedContinue NS nebulization during transport if improved

– If no improvement, contact medical control If no improvement, contact medical control physician to administer inhaled epinephrinephysician to administer inhaled epinephrine

All patients who receive nebulized epinephrine All patients who receive nebulized epinephrine mustmust be transported by an ALS unit to the hospitalbe transported by an ALS unit to the hospital



Obtain medical directionObtain medical direction– Give 2.5 ml of 1:1000 epinephrine via nebulizerGive 2.5 ml of 1:1000 epinephrine via nebulizer– A second dose may be given with medical A second dose may be given with medical

direction direction – Other interventions, such as albuterol nebOther interventions, such as albuterol neb

Albuterol and epinephrine are compatibleAlbuterol and epinephrine are compatible


Pharmacological Actions of Inhaled Epinephrine

Alpha-adrenergic receptor agonistAlpha-adrenergic receptor agonist Desired actionDesired action

– Local vasoconstriction in the large airways, which Local vasoconstriction in the large airways, which reduces airway edema and obstructionreduces airway edema and obstruction

– Caution: may have rebound edemaCaution: may have rebound edema– Decreased systemic effects with inhalationDecreased systemic effects with inhalation



Imminent respiratory arrestImminent respiratory arrest– Administer 0.01 mg/kg of 1:1000 epinephrine SC Administer 0.01 mg/kg of 1:1000 epinephrine SC

Max dose is 0.3 mgMax dose is 0.3 mg

Interventions for pediatric respiratory failureInterventions for pediatric respiratory failure– Bag-valve-mask ventilationsBag-valve-mask ventilations

May administer inhaled medications with BVMMay administer inhaled medications with BVM

– Endotracheal intubationEndotracheal intubation


BVM with Multi-Dose Inhalor Port

BVM with In-line Nebulizer

Criteria for BVM Ventilations

Inadequate RRInadequate RR– Infant/ToddlerInfant/Toddler < 20< 20– ChildChild < 16< 16– AdolescentAdolescent < 12< 12

BradycardiaBradycardia– InfantInfant HRHR < 80< 80– ChildChild HRHR < 60< 60


Criteria for BVM Ventilations

Inadequate respiratory effortInadequate respiratory effort– Absent or diminished breath soundsAbsent or diminished breath sounds– Paradoxical breathingParadoxical breathing– Cyanosis on 100% oxygenCyanosis on 100% oxygen

Cardiac arrestCardiac arrest Altered mental statusAltered mental status

– GCSGCS << 8 8


Complications of BVM Ventilations

Gastric distensionGastric distension VomitingVomiting Increased ICP due to vagal stimulationIncreased ICP due to vagal stimulation

– Pressure over the eyesPressure over the eyes


Equipment for BVM Ventilations

Appropriate size maskAppropriate size mask– Premature infantsPremature infants #0 #0

NeonatalNeonatal– Newborn - 1 yearNewborn - 1 year #1 #1 InfantInfant– 1 - 6 years1 - 6 years #2#2 ToddlerToddler– 6 - 12 years6 - 12 years #3#3 PediatricPediatric– 12 years - young adult12 years - young adult #4#4 Small AdultSmall Adult


Equipment for BVM Ventilations

SuctionSuction Appropriate size airway adjunctAppropriate size airway adjunct Appropriate size bagAppropriate size bag

– Newborn - 3 moNewborn - 3 mo NeonatalNeonatal 450 - 500 ml450 - 500 ml– Child < 30 kgChild < 30 kg PediatricPediatric 750 ml750 ml– Child > 30 kgChild > 30 kg AdultAdult 1000 - 1200 ml1000 - 1200 ml


Single Provider Technique


Two Provider

Technique


Respiratory Rates for Assisted Ventilations

Infant/ToddlerInfant/Toddler 30 - 4030 - 40 ChildChild 20 - 3020 - 30 AdolescentAdolescent 12 - 2012 - 20


Evaluate BVM Ventilations

Chest rise and fallChest rise and fall Presence of breath soundsPresence of breath sounds Skin colorSkin color Pulse oximeter readingPulse oximeter reading Presence of end-tidal C0Presence of end-tidal C022


Troubleshooting BVM Ventilations

Check size and seal of the maskCheck size and seal of the mask Verify oxygen sourceVerify oxygen source Assure proper airway positionAssure proper airway position


Troubleshooting BVM Ventilations

Disable the pressure pop-off valveDisable the pressure pop-off valve Increase the size of the bagIncrease the size of the bag Treat gastric distensionTreat gastric distension

– ALS providers: insertion of gastric tubeALS providers: insertion of gastric tube


PRESENTATION

Paramedics responded to a call for trouble Paramedics responded to a call for trouble breathing. Upon arrival they found a six breathing. Upon arrival they found a six month old with audible inspiratory stridor. month old with audible inspiratory stridor. – Mom reports that pt was recently discharged Mom reports that pt was recently discharged

after a work-up for a platelet disorder. He was after a work-up for a platelet disorder. He was having stridor last night, but was much improved having stridor last night, but was much improved this AM. No other past medical history or this AM. No other past medical history or allergies.allergies.


VITAL SIGNS

PULSEPULSE 140-160140-160 ECGECG ST without ectopyST without ectopy RRRR 30-50, labored30-50, labored OO22 SAT SAT 90% on room air90% on room air BPBP 84/4584/45 SKINSKIN Pale, warm, moistPale, warm, moist WEIGHTWEIGHT Estimated at 10 kgEstimated at 10 kg


FIELD MANAGEMENT

Pt was kept calm in Mom’s arms for transportPt was kept calm in Mom’s arms for transport Inhaled saline at 6 LPM which brought the 0Inhaled saline at 6 LPM which brought the 022

sat up to 96%. sat up to 96%. Parents refused an IV due to pt’s low platelet Parents refused an IV due to pt’s low platelet

count.count.


E. D. MANAGEMENT

Upon arrival, chest x-ray done and pt placed Upon arrival, chest x-ray done and pt placed on humidified oxygen. on humidified oxygen.

Pt received two racemic epi nebs with no Pt received two racemic epi nebs with no improvement. improvement.


E. D. MANAGEMENT

Transport team contacted and recommended Transport team contacted and recommended another racemic epi neb, an albuterol neb, another racemic epi neb, an albuterol neb, and an IM dose of steroids. and an IM dose of steroids.

Parents finally consented to peripheral IV Parents finally consented to peripheral IV insertion.insertion.


TRANSPORT TEAM MANAGEMENT

Upon arrival the pt was gray and gasping for Upon arrival the pt was gray and gasping for air with RR of 16. air with RR of 16.

Transport RN and MD agreed pt needed Transport RN and MD agreed pt needed emergent intubation. Pt received IV sedation emergent intubation. Pt received IV sedation with fentanyl and versed and was intubated with fentanyl and versed and was intubated with #3.5 uncuffed ET tube. with #3.5 uncuffed ET tube.


TRANSPORT TEAM MANAGEMENT

CXR showed right mainstem intubation. ET CXR showed right mainstem intubation. ET tube was pulled back. tube was pulled back.

Pt transported to the PICU without incident.Pt transported to the PICU without incident.


DISPOSITION

Within twelve hours of admission pt Within twelve hours of admission pt developed a leak around the ET tube and developed a leak around the ET tube and was successfully extubated. was successfully extubated.

He was discharged from the hospital three He was discharged from the hospital three days later with no ill effects.days later with no ill effects.


maryland pre-hospital protocol for croup maryland emsc program

Documents

years n

objectives n

males n

medical direction n

croup n list

symptoms of croup n

n inspiratory grunting

cylindrical n narrowest