Pediatric emergency medicine trisk 350
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hypotension, JVD, and distant heart sounds, referred to as Beck triad, are seen in
fewer than one-third of patients. Pericardial tamponade may be caused by trauma,
infection, inflammation, malignancy, or cardiac surgery. Acute tamponade may be
immediately life threatening and must be relieved expeditiously by
pericardiocentesis. In children, congenital heart defects are the most common
cause of CHF. Other cardiac causes of CHF include valvular heart disease,
myocardial dysfunction, arrhythmias, ischemia, and infarction. Metabolic
disturbances, sepsis, fluid overload, and severe anemia may also result in CHF.
Pulmonary manifestations of CHF include tachypnea, increased work of
breathing, dyspnea on exertion, orthopnea, perioral cyanosis, cough, wheeze, and
bibasilar rales. Other manifestations include pallor, poor feeding, failure to thrive,
fatigue, tiring with feeds, diaphoresis, edema, tachycardia, weak thready pulses,
JVD, displaced point of maximum impulse, cardiac murmur, gallop, rub,
cardiomegaly, and hepatosplenomegaly. Vascular causes of respiratory distress
include pulmonary embolism, pulmonary hypertension, and pulmonary
arteriovenous fistula (see Chapter 99 Pulmonary Emergencies ).
Gastrointestinal
Abdominal obstruction, perforation of hollow viscous, laceration of solid organs,
hematoma, contusion, appendicitis, infection, inflammation, ascites, or mass may
result in impaired diaphragmatic excursion secondary to abdominal distension
and/or pain. Prolonged shallow respiration may result in pulmonary
hypoventilation. Gastroesophageal reflux or vomiting, particularly in children
unable to protect their airway, may result in subglottic inflammation and/or
pulmonary aspiration (see Chapter 91 Gastrointestinal Emergencies ).
Metabolic and Endocrine Disturbances
Metabolic disturbances often manifest as compensatory alterations in respiratory
status. Metabolic acidosis results in rapid, deep breathing. Hyperammonemia
directly stimulates the respiratory center to produce tachypnea, which results in
primary respiratory alkalosis with secondary metabolic acidosis. Disruption of O2
metabolism is another cause for respiratory distress. Endocrine disturbances that
cause alterations in metabolic rate or chemical imbalances also result in
respiratory distress (see Chapter 89 Endocrine Emergencies ).
Hematologic
Inadequate concentrations of hemoglobin, or hemoglobin with decreased oxygencarrying capacity, result in deficient O2 delivery to tissues. Polycythemia results
in sludging of blood and therefore compromised O2 delivery (see Chapter 93
Hematologic Emergencies ).
EVALUATION AND DECISION
Triage and Stabilization
Every child with significant respiratory distress must be considered to be at
potential risk of progressing to respiratory arrest. Airway patency, breathing, and
circulation should be rapidly assessed and, if compromised, should be supported
immediately before further evaluation ( Table 71.6 ). Respiratory arrest can
rapidly evolve into cardiac arrest if resuscitative interventions are not timely.
Cardiorespiratory status should be continuously monitored. A healthcare
provider skilled in airway management and resuscitation should remain with the
patient at all times. Stepwise and focused evaluation is critical for determining the
source and severity of respiratory distress. In the child who is alert and otherwise
healthy, the position that he or she has naturally assumed is likely to be the one
that minimizes respiratory distress and thus should be maintained. A child with
significant respiratory distress should be allowed to remain with the parents and
should not be agitated. Agitation and crying increase minute ventilation and add
significantly to the child’s O2 consumption. Fever increases metabolic demand
for oxygen. Any patient with ventilatory compromise should be treated
immediately with supplementary O2 . In patients with decreased sensorium or
neuromuscular disease, a position to optimize airway patency must be
established. Airway devices or assisted ventilation may be necessary. For
management of cardiorespiratory arrest, resuscitation efforts must be initiated
immediately, as detailed in Chapters 7 A General Approach to the Ill or Injured
Child and 8 Airway .
History
A detailed history usually provides important clues to the cause of respiratory
distress, but in a critically ill or injured child, comprehensive details should not be
obtained at the expense of expedient patient care. A brief history can be obtained
while emergent treatment is initiated. Details can follow once the child is
stabilized. Information obtained by history should include a description of
respiratory and other symptoms, onset and duration of symptoms, possible
precipitating factors including ill contacts, environmental exposures and recent
travel, trauma, therapeutic interventions, history of previous similar symptoms,
underlying medical conditions, particularly those that predispose to respiratory
compromise, medications, allergies, and immunizations and family history of
respiratory conditions.
TABLE 71.6
LIFE-SAVING MANEUVERS TO RELIEVE RESPIRATORY DISTRESS
