Practical skills in pediatrics: common pediatric emergencies

General principles of therapy of respiratory failure:

1. Elimination of the cause that led to the development of RF;
2. Oxygen therapy;
3. Support of free airway patency;
4. Improving hemodynamics, microcirculation, oxygen transport from the lungs to the tissues, the function of tissue respiration, the elimination of disorders of oxygen-alkaline balance;
5. Reducing the load on the respiratory system.

Elimination of the cause that led to the development of RF:

• for tracheobronchial tree infections and pneumonia, antimicrobial therapy is prescribed;
• at a pneumothorax the drainage of a pleural cavity is carried out;
• in case of mechanical obstruction of the respiratory tract, the foreign body is removed.

Oxygen therapy is necessary when it is impossible for the lungs to provide normal blood oxygenation parameters (PaO2>90 mm Hg) during air respiration (FiO2 = 0.21) and can be used for spontaneous, artificial or auxiliary lung ventilation. The regimen of inhalation oxygen therapy can be short-term, continuous or intermittent depending on the severity and main physiological mechanisms of acute RI. It is also necessary to take into account the possibility of heating (37-39°C), optimal humidification (from 30 to 40 mg of water in 1 liter) of oxygen-air mixture with its appropriate concentration. The percentage of oxygen in the inhaled air depends on the method of oxygen therapy: endotracheal intubation allows to supply through a tube of oxygen at a concentration of 100% (FiO2 = 1.0), in a tent at an oxygen supply rate of 6-8 liters per 1 min - up to 30 % (FiO2 = 0.3), through the nasopharyngeal catheter - up to 40% (FiO2 = 0.4), through a tightly applied mask – up to 80% (FiO2 = 0.8), through the laryngeal mask with tamponade of the oral cavity – about 100 % (FiO2 = 1.0).

The optimal concentration of oxygen in the inhaled mixture is the minimum concentration that provides the lower allowable threshold of PaO2 (about 75 mm Hg) and SpO2 (about 95%). With marked hypoxemia, inhalation of 100% oxygen is allowed as a short-term life-saving procedure of resuscitation measures, although for longer use of oxygen-air mixture, the optimal concentration is 30-40%. It is necessary to consider the possibility of negative effects of oxygen on the child's body, especially in high concentrations in case of prolonged or improper oxygen therapy (toxic effects on the central nervous system; negative effects on lung tissue; decreased lung excursion, dehydration, burns of the tracheal and bronchial mucosa, retinal detachment, retinal hemorrhage, retrolental dysplasia, especially in premature infants, water intoxication).

Maintaining the free passage of the airways – improving the drainage function of the bronchi. To perform this, mucolytics are used to improve microcirculation – teophylline 2% solution at a dose of 0.1 ml/kg for children under 1 year, 1 ml per year of life for children after one year intravenously, warm-moist inhalation.

Improving hemodynamics – the use of cardiac glycosides: strophanthin 0.05% for children under 1 year in a single dose of 0.1-0.15 ml 1-2 times a day intravenously in 10% glucose solution slowly; after 1 year – in a dose of 0.2-0.4 ml, depending on age.

Reducing the load on the respiratory system. Ventilation is indicated in cases where spontaneous breathing or previously used respiratory techniques do not provide adequate oxygen support or removal of carbon dioxide from the body.

Indications for ventilation:

• absence of independent breathing;
• acute respiratory disorders, pathological respiratory rhythms, agonal breathing;
• clinical signs of increased hypoxemia and/or hypercapnia, if they are not eliminated after adequate therapy (restoration of airway patency, inhalation of oxygen, elimination of hypovolemia and metabolic disorders, analgesia if necessary).

Differentiated indications for ventilation:

• traumatic brain injury with signs of respiratory and consciousness disorders;
• overdose of drugs, including sedatives;
• chest injuries;
• ineffective treatment of asthmatic status;
• the presence of hypoventilation syndrome of central origin or caused by impaired neuromuscular transmission, as well as the need for muscle relaxation (epistatus, tetanus, convulsions).

Indications for mechanical ventilation in newborns:

• absence of independent breathing;
• prolonged, frequent attacks of apnea;
• severe progressive respiratory failure, cyanosis of the skin with oxygen supply> 50% in the inhaled mixture, tachypnea (> 80 per min) or bradypnea (<30 per min);
• seizures that cannot be eliminated;
• results of blood gas studies – PaO2 <50 mm Hg.; PaCO2> 60 or increase> 10 mm Hg. per hour; pH <7.2;
• even in the presence of normative indicators of blood gases, but when the child's body spends a lot of effort to eliminate aerodynamic drag, with severe stridor, Pierre Robin sequence, tumors with impaired airway patency.

Acute stenotic laryngotracheitis (croup) is an acute laryngotracheitis of mainly viral etiology, accompanied by laryngeal stenosis, hoarse voice, barking cough and stridor.

There are 4 degrees of severity of stenosis (Video):

I degree (compensated stenosis). The condition is moderate, consciousness is clear. The child is restless, periodically there is inspiratory shortness of breath, barking cough. Hoarseness of a voice is noted. Normal color of skin. Heart rate exceeds the age norm by 5-10%.

II degree (subcompensated stenosis). The condition is serious, the child is excited. Stridor breathing, rough barking cough, inspiratory shortness of breath with involvement of a jugular fossa and other pliable places of a thorax are characteristic. The voice is hoarse. Paleness and cyanosis of the skin and mucous membranes are detected, the heart rate exceeds the age norm by 10-15%.

III degree (decompensated stenosis). The condition is very serious. The child is excited or inhibited, consciousness is confused. There is a sharp inspiratory dyspnea with the participation of auxiliary muscles, exhalation is shortened. Skin and mucous membranes are pale, earthy color, characteristic acrocyanosis, cold sweat. Symptoms of circulatory failure are developed: marbling skin, heart rate exceeds the norm by more than 15%, deafness of heart sounds, frequent arrhythmic pulse, enlarged liver.

IV degree (asphyxia). The condition is extremely severe, there is no consciousness, the pupils are dilated, and seizures often occur. Shallow breathing. The skin is cyanotic. A formidable sign is bradycardia, which precedes cardiac arrest.

Emergency aid (Video). Emergency physicians should perform oxygen therapy to prevent hypoxia and acidosis. If the patient has a clinic of severe RF, it is necessary to perform a cricothyrotomy. To do this, place the child on his back with his head outstretched (roller under his shoulders) and after treating the skin with antiseptic and "lemon peel" local anesthetic, perform a dissection of the membrane between the thyroid and annular cartilage and cricoid cartilage dilution to the sides.