Emergency Situations in the Pediatric Cardiac Patient, by Toni Imprescia.
Hi, my name is Toni Imprescia.
on the clinical educator I'm the clinical educator at Boston Children's Hospital in
the Cardiac Intensive Care Unit.
I'm here today to talk to you about emergency situations in the pediatric cardiac patient.
Pediatric patient population is at risk for respiratory distress and respiratory failure
for several reasons.
Children have a high metabolic demand, which increases their tissue oxygen consumption.
A room air saturation of less than 94% indicates hypoxemia.
In children with unrepaired congenital heart defects that have right-to-left shunting of
blood live with oxygen saturations between 70%-80%.
Some patients might include defects such as Tetralogy of Fallot.
Those patients live in a constant state of respiratory distress.
Children with hypoxemia initially compensate by increasing the respiratory rate and respiratory
effort.
To maintain oxygen tissue delivery, the child will become tachycardic increase cardiac output.
Respiratory Distress and Failure.
Respiratory distress is a clinical state characterized by increased respiratory rate and increased
respiratory effort.
Respiratory distress can range from mild to severe.
Clinical signs of respiratory distress include changes in breath sounds, skin color, agitation,
or anxiety.
Children with congenital heart disease may live in a constant state of respiratory distress
until a surgical repair can be done.
When an additional burden - such as a respiratory infection or pulmonary edema - occur, the
patient may not be able to compensate to maintain adequate ventilation.
The effort of compensating is too great, and the patient tires.
When this happens, clinical signs of respiratory failure develop.
Respiratory failure is a state of inadequate oxygenation, ventilation, or both.
Clinical signs of respiratory failure include increased or decreased respiratory rate and
effort, increased or decreased heart rate, cyanosis, poor to absent aeration, lethargy,
or coma.
Respiratory failure requires intervention to prevent respiratory arrest and ultimately
cardiac arrest.
Respiratory distress and respiratory failure can be caused by hypoxemia.
Early signs of tissue hypoxemia are tachypnea, tachycardia, nasal flaring, retractions, agitation,
pallor, and fatigue.
Late clinical signs of tissue hypoxemia are cyanosis, slow respiratory rate, bradycardia,
and altered mental status.
Another cause of respiratory failure is hypercarbia.
Hypercarbia is the buildup of carbon dioxide in the blood from inadequate ventilation.
Clinical signs of hypercarbia are altered mental status and an increased respiratory
rate.
Respiratory rate increases to remove the excess carbon dioxide through exhalation.
It is important that hypoxemia can be detected through pulse oximetry.
However, hypercarbia needs a blood test to be detected.
A patient in respiratory distress who is being treated with oxygen may demonstrate an adequate
oxygen saturation but still have hypercarbia from impaired ventilation, and this might
not be detected by external measurement.
Clinical assessment is crucial to provide appropriate therapy.
In children, clinical deterioration in respiratory function may progress rapidly.
Children can compensate for a very long time and then decompensate in a very, very short
period of time.
For this reason, it is important to act quickly when signs of respiratory distress occur.
To optimize patient outcomes, caregivers must intervene rapidly to restore normal respiratory
function.
Once respiratory arrest progresses to cardiac arrest, outcomes are generally poor.
The initial treatment should include support to restore adequate oxygenation and ventilation.
Your first priority is to evaluate the airway and the patient's breathing.
You want to support the airway.
Place the patient in a position of comfort.
Open the airway and clear any secretions that might be obstructing or blocking air entry.
Next, you want to assess breathing.
Is the patient breathing?
And provide oxygen.
Continuously monitor oxygen saturation, if available, and assist in ventilation if necessary
with a bag mask if needed.
If the patient's in extreme distress, you want to begin preparation for intubation as
soon as possible and have everything on hand so intubation can go smoothly and quickly.
While you're assessing the airway, it is crucial that someone is assessing the patient's circulation.
Assure that the patient has an adequate heart rate and heart rhythm and that there are palpable
pulses.
This is also a good time to assure that the patient has adequate intravenous access available
in the event of an emergency.
Some common causes for respiratory failure include pulmonary edema, respiratory infections,
and stridor following extubation, along with pleural effusions.
Pulmonary edema is the buildup of fluid in the tissue of the lungs, most commonly caused
by congestive heart failure.
The management of pulmonary edema includes adding supplemental oxygen via a nasal cannula
or by providing CPAP, Continuous Positive Airway Pressure, or intubation support.
You can administer medications, including diuretic therapy, to increase fluid removal.
Also, adding inotropic support may help improve myocardial function and increase cardiac output,
thus improving removal of the fluid.
Afterload reducing agents may also be helpful to decrease the workload on the heart.
In terms of respiratory infections, for children with congenital heart disease, they are extremely
susceptible to respiratory infections that can lead to bronchiolitis and pneumonia.
Care should be taken to prevent exposure and possible infections.
However, when an infection is suspected, these children require close observation.
If the infection is caused by a bacteria, treat with proper antibiotic therapy and treat
the symptoms to support the patients respiratory function if the infection is caused by a virus
you would treat the symptoms and treat the symptoms to support the patient's respiratory
function.
Stridor post-extubation is a condition that can occur following repair for the congenital
heart defect.
Children are typically intubated for a period of time following their surgeries.
After extubation, monitor for the presence of stridor.
[HEAVY, LABORED BREATHING] Pleural effusions are a buildup of fluid between the layers
of tissue that line the lungs and the chest cavity.
The buildup of fluid leads to decreased lung volumes.
When this condition exists, you may provide diuretic therapy to help improve removal of
excess fluid, or the patient may require a therapeutic thoracentesis to be done to help
remove the fluid collection.
If the collection is large, this may cause increase in chest pressure, shortness of breath,
other breathing problems, and low oxen saturation.
Removing the fluid will allow
the lung to expand, making breathing easier, and
improve
oxygenation
and
oxygen saturation.