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Would you know what to do if you had to treat a child with severe breathing difficulties? Would you know what to look for in your assessment? And would you know what to do if your initial treatments weren't working? I'm Doctor Matthew Sayers, a consultant, pediatrician. And in this video, I'm going to take you through how to manage a child from severe wheeze from arrival to admission. This will be the first of a series of videos called situation which will take you through how to manage pediatric emergencies, especially useful for ed doctors, medical students and new pediatric doctors. This will be an interactive stimulation. So pause the video when prompted and think about or write down what you would do at each step. There are some useful resources in the video description to help you with this when you're ready. Let's get started. Imagine you're a new ed doctor working in recess. The triage nurse brings through a three year old child with their mum. You can see that they're breathing very rapidly. And the triage nurse asks you to assess them urgently, pause the video, think of three key questions that you would like to ask the mom during your assessment, remember that this child is very sick. So you cannot take the full pediatric history and background like you normally would. So you're going to focus your history taking on key questions that will help you in your decision making. You could have asked any of the following. How long has he been struggling to breathe? Has he had any similar episodes before or does he have a diagnosis of asthma? Is there any barking cough with his breathing problems? Uh, could he have choked or swallowed on anything? Is there any lip swelling or unusual rashes? Has he had any temperatures or runny nose in the run up to this? His mum tells you that he had a cough and runny nose for the last few days, but he had been very well this afternoon, he developed a worsening cough and for the last hour, he has had um very rapid and labored breathing which concerned her. So she brought him to the emergency department. She hasn't noticed any barking cough, any history of choking or any lip swelling or abnormal rashes. He's never had anything like this before. Now, move on to your ABCD E assessment. Pause a video and think about what positive findings you're hoping to see. For example, wheeze or crepitations and also what negative findings you want to rule out. For example, you want to rule out a prolonged cap refill time or um severe skin rash. We will now undertake our clinical assessment. We will firstly assess airway, the airway is patent and the child is alert and speaking in short sentences, we will put on a saturation probe and an ECG lead. You can see the the monitor is now displayed on screen. We will also put an oxygen mask on. We'll fill the non rebreather bag uh with 15 L of oxygen and put it over the child's face. We will now assess the child's breathing. We will um expose his chest and we can see there's severe tracheal tug, intercostal and subcostal recession indicating severe effort of breathing. We will now auscultate the chest. Yeah. Uh yeah. Oh yeah. And um uh listening on both the front and back of the chest and also listening to the heart, we can hear severe bilateral wheeze with reduced air entry at the bases on looking at the monitor. We can also see the saturations are 90% on non rebreather oxygen. We can also count the child's respiratory rate and we've counted it at a rate of 45. You can see on the monitor that there is a respiratory rate given. However, this is not very accurate and counting the respiratory rate is the most accurate method. We'll now move on to the c part of the assessment circulation. You can see on the monitor whose heart rate is 100 and 43 with normal sinus rhythm. We'll check a central cap refill time 1 1002, 1003, 1004, 1005, 1000, 1 1002, 1000. The central capri full time is less than two seconds. We can feel the child's hands and feet and we can feel that they are warm and well perfused. We will also check a BP. White BP is a useful clinical parameter. Do not rely on it as a measure of shock as it is often one of the last things to be affected in a child with shock. You can see the child's BP is 100/60 with a map of 73. You can also remember from auscultating the child's chest that there were no murmurs. Now I move on to the d part of our assessment disability or neurological status. We can see that the child is alert although he is scared, we check his blood sugar and his blood sugar is 4.7. Finally, we move on to expose and examine whilst maintaining the child's dignity and temperature control. We check his temperature and note it to be 38.5 degrees on examination. We don't see any other rashes or bruising. Uh the nurse weighs the child and their weight is 20 kg. Pause the video and consider your findings. You can use the PS chart and other resources linked in the video description to confer your observations to age appropriate clinical values. Consider what you think is going on with this child and why you have now completed your first assessment cycle. And you need to think what you're going to do next. The key resources in an emergency are personnel and time. If you need additional help in terms of experience and also numbers and make sure you ask for them early. If you have multiple people to help you, you will be able to delegate multiple jobs at once, but make sure the team that you have available are able to do the jobs that you are giving them. You always need to maintain your situational awareness in an emergency and time is a limited resource. So always make sure you prioritize the interventions that will make the most difference to the patient and will tie you up for the least amount of time. So you can maintain your focus on the bigger picture, more time consuming tasks. For example, an external referral to P ICU should be delegated or deferred until the child is stabilized just in mind, plan your next step. Some common tasks that are often performed in an emergency department are shown on screen. Think about your level of expertise, how long each task will take and what benefit it will be for the child in making your decision. I would start by prescribing three salbutamol and ipratropium bromide combination nebs as well as oral steroids, either prednisoLONE or dexamethasone. These will provide immediate benefit for the child and can be given by nursing staff. While you do other tasks, I would then call for senior help within your department, preferably from an experienced doctor at middle grade level or above. If you're not experienced in pediatrics, it is important to call for senior help early as Children can deteriorate very quickly. You could also contact a middle grade pediatrician for help. However, you should discuss the patient with an ed middle grade doctor, first anesthetics or P IC referral is not required at this stage. You may have chosen to take bloods, get a chest X ray or update parents. None of these answers are wrong and they way well be required at some point during this scenario. But it's important to prioritize the most important and beneficial interventions. First, the history and examination is suggestive of either viral and just wheeze or acute asthma. There is nothing to suggest croup sepsis, anaphylaxis or an inhaled foreign body, which would be the main differential diagnosis in a wheezy child with a severe respiratory distress. You decide to prescribe back to back nebulizers, oral prednisoLONE and ask your ed registrar to review you write your note and review the child again 15 minutes after their last nebulizer, their airway is patent but they are now a bit confused. Their respiratory rate is now 50 per minute and their saturations are 89% on 15 L of oxygen. On examination of their chest. There is severe accessory muscle use with tracheal tug, intercostal and subcostal recession. Yeah. On listening to their chest, there is now poor air entry in all areas and there is minimal. Wheeze her cap full time is less than two seconds and their heart rate is 165. Their BP is 100 and 10. Over 69. There are no other changes to their rashes or skin. Pause the video. What are your next steps? Child has deteriorated despite the use of nebulizers and steroids. The reduction in the degree of wheeze is not a reassuring finding. As combined with the absence of clear air entry into the lungs. It likely means that the efficacy of breathing is reducing. There are also signs that the effects of breathing are reducing with low saturations and new confusion. This child is severely unwell and urgent action is needed to prevent them deteriorating into apnea if you have not already done. So you need to call for senior help urgently. This should be in the form of the most experienced doctor in the emergency department and also a middle grade pediatrician or above. Additional personnel will also be required so that you can delegate jobs and maintain your situational awareness in the emergency. You will need to insert an IV cannula at this stage. As IV therapy is also required as you do this, you should take blood tests including a full blood count, ec RP, bone profile, magnesium level and venous blood gas there is rarely ever an indication for an arterial blood gas in pediatrics outside of P ICU. Remember pediatric cannulas are very difficult in young Children and you will need an experienced nurse to help you hold the child. Ideally, um someone experienced in pediatric blood taking should do the cannula in an emergency. But this is not always possible. Once you have IV access, it is a priority to give IV medication. In this situation. I would give IV magnesium sulfate and reassess the child following this. If there's been no improvement or insufficient improvement, I would give a loading dose of IV aminophylline. If you have sufficient staff now would be a good time to update parents on the situation as they are likely extremely worried. Ideally, it can be helpful to provide short regular updates as you're doing clinical tasks. But you should always prioritize um treating the child in an emergency rather than providing updates. If there are sufficient staff, the team leader can be a very useful person to update parents as they have been involved in the whole treatment course and are in a position of authority always ensure that you maintain your situational awareness while updating parents. However, you give IV magnesium followed by a loading dose of IV aminophylline and the ed consultant and pediatric registrar arrive to assist you. A venous blood gas is obtained. It shows a ph of 7.22 A P CO2 of nine A bicarb of 30 base excess of positive two and a lactate of four. Pause the video and consider the podcast. What does it show? Are you concerned about the high lactate? The PH is low indicating an acidemia. The P CO2 is very high and the bicarb and base excess are both normal. Whilst uh venous blood gas will have a naturally higher P CO2 than an arterial blood gas. This is still very elevated and concerning we would expect in a child with a very rapid respiratory rate for the PC two to be low. So a high CO2 indicates that the efficacy of breathing is low lactate is actually a red herring. In this case, uh high lactate generally indicates pear tissue and organ perfusion. However, in this case, it is elevated as a waste product of medical therapy and is not a prognostic marker of acute wheeze. If there are associated features of per perfusion, for example, and elevated cap refill time, we do need to take lactaid very seriously. However, you perform another reassessment of the patient. Their airway remains potent but they are now very drowsy. Their work of breathing appears to be reduced and there is no air entry, um audible on auscultation. Their respiratory rate is now 30 their saturations are 79% on 15 L. Nonrebreather mask. Their central cap refill time is less than two. Their BP is 100 and 10/69 and their heart rate is 100 and 84. Their disability assessment shows uh drowsiness but no other focal abnormalities and their blood sugar is normal. There are no new rashes, watch the video. What is your next step? Child is continuing to deteriorate and apnea is rapidly approaching. You need to fast ble an anesthetist urgently and contact P ICU to discuss transfer. Close the video. Imagine you're going to call the regional P ICU which work in another hospital. Remember they do not know anything about this patient or what you have done. Think about what questions they are likely to ask and what information you need available. Structure. Your handover in an sbar format, anesthetic consultant attends and thanks to your well structured handover, the child is accepted for P ICU transfer. They are transferred up to theaters and you can take a short but well earned break in the E VT room. Well done. We will now spend some time on debris for this virtual simulation. Well done if you were clear on your approach and management plan. But don't worry if not, I will take you through how to approach this case in a structured way. Remember to think how you would feel emotionally in a case like this as often, it's much easier to make clinical decisions when you're not in an emotional emergency. Your initial history gives the suggestion of a child with a mild viral illness and respiratory difficulties. Your clinical assessment shows a child with an elevated respiratory rate, severely increased work of breathing and low oxygen saturations on room air with associated widespread wheeze his heart rate and temperature are mildly elevated but there is nothing to suggest a significant CD or E problem on assessment. This presentation is very typical of viral in wheeze, in case you're confused, don't worry, the assessment of and management of acute asthma and viral in wheeze are entirely identical. You can see the acute asthma severity score on screen for this child. This would be a severe exacerbation due to the fact that he cannot complete sentences in one breath. There is moderate accessory muscle use. His saturations are less than 92% on room air. His respiratory rate is greater than 40 his heart rate is greater than 100 and 40. Note that peak flow is not used routinely in acute asthma exacerbation in Children. You can now see the treatment algorithm for acute severe wheeze below. Hopefully, you will have put additional oxygen on the child. Whilst the guideline says to aim for saturations of 94 to 98%. Children do not get oxygen induced CO2 retention. So there is little risk from excessive oxygen therapy nebulizer should also be prescribed. The guideline mentions getting salbutamol and ipratropium. In combination every 20 minutes. In practice, we do this by prescribing three back to back nebulizers. This means that once one nebulizer finishes another one is immediately put on for three in total nebulizers are filled in this chamber and attached as shown, they are then attached to the wall with an oxygen delivery at around 8 L as any higher than this will cause it to pop off the wall. You can see a mist thing um coming into the mask. And when this miss thing is finished, this means that the nebulizer is complete. Wellbutin nebulizers can be given back to back indefinitely if required. But remember that severe tachycardia sickness and other features of toxicity can occur with repeated use. Um Also remember that salbutamol drops potassium levels to make sure that this is monitored if repeated, salbutamol is used and oral supplementation given if required. By contrast, three initial ipratropium meds are generally given and then not repeated for at least 6 to 12 hours. This is because the receptors are quickly saturated by ipratropium nebs and further therapy. Beyond the initial three is not beneficial in less severe exacerbations. 10 puffs via spacer of salbutamol inhalers can be given in preference to nebs and this is as effective if given correctly, steroids should also be given. There is various practice between units about what is used. The British Thoracic Society still recommends oral prednisoLONE as first line but many units are using dexamethasone. This is because it has been shown not to be inferior to prednisoLONE. Um it is better tolerated and it also only requires one dose compared to a three day dose of oral prednisoLONE, hydrocortisone is another alternative if you have IV access and the patient is very unwell. But there is no evidence that IV hydrocortisone is superior to oral steroids. Nebulized steroids are not routinely used in acute asthma exacerbations. Magnesium is mentioned in some guidelines, but this has not generally been established practice in an emergency if the child is continuing to deteriorate. Despite your initial treatment, consider the differential diagnosis in case your initial assessment did not arrive at the correct diagnosis. In this case, acute croup would be unlikely due to the absence of a barking cough and no signs of stridor. Uh lower respiratory tract infection or chest sepsis would be unlikely due to the presence of widespread wheeze. Uh an absence of shock and a very acute onset of symptoms. Uh history of anaphylaxis would also be unlikely due to the lack of clear trigger, no significant rash and no features of shock. An healed foreign body would also be unlikely due to the absence of history. The presence of widespread wheeze and the child not being in a typical age range for this condition. If in any doubt, a chest X ray can be used to confirm bronchiolitis is unlikely in this case as this child is over one and most bronchiolitis presents in the first year of life. Any child presenting with acute wheezing respiratory distress under the age of one should not be managed in this way. In this video and a future video will um go into more detail on the management of bronchiolitis. In our second assessment cycle, the child had deteriorated to life-threatening asthma due to the presence of confusion, maximal accessory muscle use a silent chest and marked tachycardia. Remember that in severely unwell patients less wheeze equates to less air movement, not improving asthma, an intravenous bolus of magnesium sulfate, 40 mgs per kilogram should be given with continuous ecg monitoring over 20 minutes. If there is no improvement over this, the guideline suggests the use of either IV salbutamol or IV aminophylline. In practice, IV aminophylline is usually prepared. This is given as a bolus over 20 minutes again with ECG monitoring and a regular maintenance infusion can be used following this if required. The child should be discussed with P ICU and have an anesthetic assessment. In practice, most Children are managed with IV therapy and continuous nebulizers on the ward or HD U setting and are not intubated. This is because it is very difficult to intubate Children with asthma or viral and just wheeze and high ventilator pressures are required due to the presence of air trapping. This X ray should be performed to ensure there is no infection, uh entailed foreign body or pneumothorax. Complicating the case for most Children with uncomplicated viral induced wheeze or asthma. A chest X ray is not required despite what it says on the guideline. Um ABG is very rarely performed outside of AP ICU setting. Hold on on your management of this scenario, pause a video and think of one learning point that you will apply to your real life practice. If you have any questions about the management of wheezy Children or any sick Children in general, put them in the comments and I will respond as quickly as possible. Thanks so much for watching. Please like this video, comment with any clinical questions or feedback you have and subscribe to the channel and our other social media accounts including Instagram, Twitter, Med all and Ola to stay up to date with future videos. I look forward to seeing you again soon.