Always start your assessment with your ABCs. Determine if a patient can protect their airway. If they cannot, establish one for them. Suction, repositioning, and removal of a physical obstruction are some examples of ways to protect an airway. Consider airway adjuncts or advanced airway if the patient needs it. If no contraindication exists (i.e., the need for spinal precautions), the lateral decubitus position may be advantageous for airway protection. Remember that respiratory rate and depth and pulse oximetry can assist in determining if there is a need to improve oxygenation. If apneic or hypo-ventilating, start ventilations immediately with Bag-Valve-Mask. Remember that hypoxia can be a cause or effect of AMS; therefore, please treat these patients with supplemental oxygen or non-invasive positive pressure ventilation (NIPPV) (e.g., CPAP, BiPAP) when needed. These devices improve ventilation, gas exchange, and CO2 removal. Recall that patients should have an adequate respiratory drive for NIPPV to be used. Do not forget your end-tidal CO2 monitoring.

Significant fever, hypothermia, or hyperthermia can predispose patients to altered mental status, so be sure to assess heart rate, blood pressure, and temperature. Abnormalities in these may also indicate various shock states or cardiac dysrhythmias. Remember to assess for AVPU:

• A = the patient is Alert

• V= the patient responds only to loud Verbal stimuli

• P= the patient responds only to Painful stimuli

• U = the patient is Unconscious / Unresponsive

Examine for any obvious signs of trauma (scalp or facial lacerations, abrasions, and contusions).

Pupils should be observed for symmetry and light reactivity. Bilateral mydriasis may indicate cerebral hypoxia or a toxicological etiology (e.g., anticholinergic, sympathomimetics, SSRIs, etc.)

Miosis (opiate overdose, organophosphates, antipsychotics, sedative-hypnotics, and pontine stroke). Signs of brain herniation from trauma or spontaneous intracranial hemorrhage (Cushing’s triad: widened pulse pressure, bradycardia, and irregular respirations) should not be missed. Odors on the breath may provide clues. For example, if the patient’s breath smells like acetone (a fruity smell resembling nail polish remover), that may be a sign of elevated serum ketones. The smell of bitter almonds is concerning for cyanide poisoning. Any upper airway stridor should be documented and plans to care for a partially or soon-to-be obstructed airway must take precedence. The cervical spine should be evaluated for any step-offs, deformities, or penetrating trauma. If any of these are present, then cervical spine precautions should be applied. 

That is all for this week. We will continue our discussion of the assessment of altered mental status next week.

Thank you for all the great work you are doing out there. Have an amazing week. 

Regina Yaskey, MD.

Good Morning,

I know that we have been discussing altered mental status this month, but due to respiratory season and your requests for a refresher on pediatric respiratory emergencies, I am deviating and covering these timely topics this week. Bronchiolitis (RSV) is back. Influenza (the flu) is back.

Respiratory emergencies account for a significant portion of childhood emergency department visits and hospital admissions. It is the number one cause of cardiopulmonary arrests in children. One important thing to remember is that children are “not just little adults.” They have smaller airways, increased metabolic demands, decreased respiratory reserves, and inadequate compensatory mechanisms. . It makes visualization of the pediatric airway more difficult. Remember that neonates are obligate nose breathers. Their airway is so much smaller than that of an adult; therefore, any edema or secretions can have a much bigger impact on their breathing. This is why it is so important to keep these kids calm. Even minor colds can result in a lot of noisy breathing, such as congestion, stridor, and wheezing.

Early recognition of pending respiratory failure is vital when examining these children. Make sure that you carry out your assessment in a step-by-step approach. Ask yourself, “Is this child in respiratory distress?” What interventions must be done now to prevent respiratory failure? Resuscitation courses teach us about Airway, Breathing, and Circulation. In Pediatrics, please add an additional “A” for “Appearance.” The appearance of the child is extremely vital to how you approach their evaluation and management. A brief assessment to determine whether they are “sick or not sick” tells you a lot. Make sure to observe their level of alertness or activity. Are they active and curious, staring around the room? Do they look pale, or are they mottled or cyanotic? Do they have a normal tone or appear “floppy”, and are they refusing to move out of a certain position? 

Be mindful of their respiratory mechanics. Monitor closely for marked increased work of breathing (grunting, nasal flaring, subcostal, intercostal, and suprasternal retractions) or decreased respiratory effort (which indicates fatigue and is concerning for impending respiratory failure). Listen to their voice or cry. Is it hoarse or muffled? Do they have stridor, or are they wheezing? In a verbal child, are they able to speak in full sentences, or are they using one-word sentences to answer your questions?

Respiratory Illnesses of the lower airway are obstructive, parenchymal, or alveolar diseases. The clinical hallmarks include dyspnea, tachypnea, and cough. Common causes include:

• Bronchiolitis

• Asthma

• Congenital abnormalities (tracheal webs, cysts, vascular rings, and lobar emphysema)

• Pneumonia

• Pulmonary edema

• Inhalation injury

• Cystic fibrosis

• 
  

BRONCHIOLITIS, a viral infection, is a lower respiratory tract infection of the bronchioles (small airways). It usually presents in the winter–spring months and is seen in children who are less than 24 months old. Respiratory Syncytial Virus (RSV) is the most common cause. Clinical signs are similar to those of a viral respiratory infection. These children usually start with a prodrome of nasal congestion, rhinorrhea, fever, cough, wheezing, and mild respiratory distress. Additional signs and symptoms include apnea, decreased oral intake, and moderate to severe respiratory distress (tachypnea, nasal flaring, and retractions, grunting), cyanosis, restlessness, and lethargy. Risk factors for severe disease include children less than 12 weeks old, history of prematurity (less than 37 weeks), history of congenital heart disease, history of chronic lung disease, and history of immunodeficiency. 

The course of bronchiolitis is variable and dynamic. It ranges from transient events such as apnea or mucous plugging to progressive respiratory distress from lower airway obstruction. Symptoms are usually worse on days 3 – 5 of illness. Determining the degree of airway obstruction is the most important consideration when assessing children with bronchiolitis. Examine their general appearance, degree of respiratory distress, cyanosis or pallor, and their level of oxygen saturation. In route, when dealing with these patients, give them supplemental oxygen if the oxygen saturation is consistently below 92%. Insert an IV and administer fluids if they appear to be dehydrated. If wheezing is present, a trial of a bronchodilator (Albuterol) is an option. Please auscultate before and after the albuterol administration in order to determine if it made a difference in the patient’s air exchange or work of breathing. 

ASTHMA accounts for 15% of all emergency department visits. It is a chronic inflammatory lung disease. Symptoms include paroxysmal cough, wheezing, dyspnea, and chest tightness. It is caused by airway inflammation and narrowing that is partially or completely reversible. Precipitating factors include infection, allergens, irritant exposure (tobacco smoke, air pollution), exercise, cold exposure, beta-blockers, and emotional stress). With a patient with asthma, your goal is to rapidly determine the severity of the acute exacerbation and examine their overall appearance (color and level of consciousness). Their respiratory mechanics are important. Look for tachypnea, retractions, nasal flaring, grunting, abdominal breathing, and prolonged expiratory phase. When auscultating, listen for their degree of air exchange  In severe exacerbations, the child may be breathless, have difficulty speaking in complete sentences, and may have a change in mental status (remember that hypoxia can cause agitation, and hypercapnia causes drowsiness or coma). Treatment for acute asthma exacerbations includes oxygen and duo-nebulizer treatments (Albuterol and Ipratropium). These treatments can be repeated en route if the work of breathing persists. In severe exacerbations, insert an IV or IO, administer fluids for hydration and add Solumedrol (2mg/kg ; Max Dose: 60mg for children). Transport the patient to an appropriate facility. Remember to consult Medical Control when indicated. 

Thanks to everyone who reached out requesting a refresher on respiratory emergencies. I am always ready and willing to do lectures for your agencies when needed. You can also reach me at Regina.Yaskey@uhhospitals.org with any questions. Happy to help and answer questions anytime. 

Next week, we will return to discussing altered mental status. Thanks for all the great work you are doing. Have a happy and healthy Thanksgiving. 

Regina Yaskey, MD.

Good Morning,

Hope you all had a wonderful Thanksgiving weekend. This week we will reconvene with our discussions on the assessment of patients presenting with Altered Mental Status (AMS).

Chest:

When examining the chest, note the respiratory rate, pattern, and depth. Observe for any outward signs of trauma. Auscultation can identify rhonchi, crackles, wheezing, or lack of breath sounds. This can aid in identifying a possible infection, volume overload, asthma/COPD exacerbation, or pneumothorax as the cause of AMS due to decreased oxygen supply to the brain. 

Abdomen:

Examine the abdomen for signs of blunt or penetrating trauma or distention. In females of child-bearing age, with gravid-appearing abdomens, pregnancy and its complications (e.g., eclampsia, HELLP syndrome, and ectopic pregnancy), palpate the abdomen to identify any rigidity or tenderness.

Neurologic:

Examine for abnormal pupillary findings. Focal neurologic signs suggesting stroke or increased intracranial pressure should be noted (e.g., Cushing’s triad: hypertension, bradycardia, and irregular respirations). Seizures, seizure-like activity, loss of bowel or bladder tone.

Stroke Scales can be helpful.

–    Cincinnati Prehospital Stroke Scale

–    Los Angeles Prehospital Stroke Screen

–    Rapid Arterial Occlusion Evaluation (RACE) – considers large vessel occlusion

Skin:

Skin is used to estimate temperature. It is increased in infection or heat illness and decreased in cold exposure, dehydration, or alcohol barbiturate overdose. Rashes indicate infection or allergic reactions. Track marks show us needle injections and lead us to a differential of possible drug overdose. In that case, please make sure to log roll and examine the patient from head to toe (look for transdermal drug patches, insulin pumps, dialysis access, petechiae, occult puncture wounds, and subtle other findings). 

Remember to get clues from the scene. Seek additional information from alternative sources (bystanders, family, and physical surroundings). Search common locations (bathrooms, medicine cabinets, bedrooms, nightstands, and kitchens) for clues about underlying illnesses or possible ingestions.

Important questions to ask include but not limited to:

• Patient’s baseline health

• Past medical history

• Current prescribed medications

• The rapidity of the onset of symptoms

• Loss of consciousness?

• Seizure-like activity

If a drug(s) overdose is suspected, remember to get information on the following:

• Route of exposure

• Type of substance involved.

• Time and amount of exposure

• Empty pill containers

• Liquor bottles

• Syringes

• Other drug paraphernalia

Note and document any actions taken by the patient or bystanders. Most treatments in these cases are supportive. If available, administer antidotes. Evaluate and treat abnormal vital signs. Lastly, remember your ABCs and rapidly identify and treat reversible conditions.

Thank you for all the great work that you do. Hope you have a wonderful holiday season with your families. 

Regina Yaskey, MD