Simulation

Pediatric Bronchiolitis

Primary Objectives:

             1.) Correctly recognize and develop a differential for a child with respiratory distress

             2.) Identify appropriate lab work that needs to be ordered for evaluation

                             a.) none need to ordered unless decompensating

             3.) Correctly use the respiratory score for Bronchioitis

             4.) Know proper technique for suctioning and BVM

Secondary:

1.)    Recognize when patient needs HFNC and further escalation

a.   Rtx, ram cannula, intubation

             2.)  Recognize what you might see on a chest x-ray if ordered

             3.) Identify medications commonly tried

                             a) albuterol, racemic epi, hypertonic saline

             4.) Identify and assign roles required for managing unstable pediatric patient

Tetralogy of Fallot Teaching Points

Overall Case Flow:

-        Patient initially presenting to ED for cyanotic spells

-        History of unknown heart defect, recognize that it is Tetralogy of Fallot based on physical exam (murmur resolves  with spell), EKG, and CXR findings

-        Treat Tet spells appropriately

Goals/Learning Points:

1.     What is Tetralogy of Fallot (ToF)?

        Four abnormalities that make up Tetralogy (pneumonic: PROV):

        1.     RV outflow tract obstruction (RVOT)

                  -        Sub-pulmonary and pulmonary valve stenosis

                  -        Degree of cyanosis is dependent on the degree of RVOT - only a proportion of blood is able to cross the      RVOT and the rest shunts from R > L across the VSD to be ejected out of the aorta

        2.     RVH

        3.     Overriding aorta

        4.     VSD

2.     Classic presentation:

        a.     Infants: Tet spells arise when infant becomes agitated or upset: hyperpnea (rapid and deep respirations), irritability, inconsolability, and progressive severe cyanosis

        b.     Older child: Cyanotic child who squats after exertion - this is because squatting increases SVR and increases   oxygenation (decreases R > L shunt).

        c.      If cyanosis present, it is most easily seen in the nail beds and lips

        d.     Physical exam findings:

          i. May appreciate a prominent RV impulse and, occasionally a systolic thrill

                ii. Hepatomegaly uncommon

                iii. Peripheral pulses usually normal

                iv. Auscultation: 

                        1.     S1 = normal, S2 = most commonly single because the pulmonic component is rarely audible

                        2.     murmur (systolic, crescendo-decrescendo w/ harsh ejection quality, best along the left mid- to upper sternal   border with radiation posteriorly)

                               a.  Due primarily to the RV outflow obstruction & to the amount of flow across the obstruction, NOT the VSD

    b.  The amount of flow across the RVOT will decrease as the obstruction increases, due to the shunting of blood R > L across the VSD. Thus, as the obstruction increases, the murmur will become softer

3.     Diagnosis

        a.     Transthoracic ECHO (many found prenatally), other tests often performed: EKG and CXR

Imaging:

CXR: “Boot-shaped” Heart: Upturned apex & Concave Pulmonary artery

EKG:

• Signs of RVH:

     A.) Right axis deviation (axis down in I, up in aVF)

     B.) Pure R wave in V1/no r wave progression from V1-V3

     C.) S wave in V4-V6; dominant S wave in I-III

     D.) Upright T in V1 before 10 years of age

* RVH may be normal until 6mo of age.

4.     Oxygenation for patients with ToF?

1.     Systemic oxygen > 75% is considered adequate. If unable to do this, the patient will require surgical correction.

2.     Shunting is depending on relative pulmonary/systemic vascular resistance. Increased PVR and decreased SVR worsens the R > L shunt therefore worsening cyanosis.

-        Increase PVR: bearing down, screaming, reflux/aspiration

-        Decrease SVR: eating, vasodilation, heat

5.     Treatment of tet spell or hyper cyanotic spell?

Increase SVR/decrease PVR

Maneuvers

-        Calm the child (decrease PVR)

-        Bring knees to chest (increase SVR promoting movement of blood from RV into pulmonary circulation rather than aorta)

-        Give O2 (decrease PVR = pulmonary vasodilator and systemic vasoconstrictor)

Medications

-        Give IVF bolus (increased preload) and IV morphine (MOA unclear)

-        IN fentanyl/versed as alternates

-        Give a beta- blocker, slows down the heart rate and allows increase the right ventricular filling which can decrease the right ventricle outflow obstruction

-        Phenylephrine if beta blockers are ineffective (increases systemic afterload = promotes RV flow into the pulmonary circulation)

-        ECMO as last resort

6.     Treatment in neonates:

1.     Often are asymptomatic, but prostaglandin is helpful if the baby has severe cyanosis. If an infant requires prostaglandins they will require surgical correction before discharge.

2.     Typical surgical correction occurs between 6 to 12 months of age, but sometimes earlier.

-        There is an association with ventricular arrhythmias in post-op ToF with residual pulmonary stenosis or insufficiency

7.     More important information:

1.     Murmur is due to RVOT, systolic ejection murmur at left upper sternal border. During a Tet spell, there is very little flow across the RVOT so the murmur may disappear

2.     CXR: boot shaped heart  and decreased pulmonary vasculature

3.     EKG:  RAD and RVH

4.     ECHO is diagnostic

5.     Associations: DiGeorge Syndrome, CHARGE syndrome, Alagille Syndrome, Trisomy 13, and Trisomy 18.

8.     Review how to interpret EKGs.

EKG Resoures: 

1) ResearchGate  Evans W, Acherman R, Mayman G, et al.  Simplified Pediatric Electrocardiogram Interpretation. Clinical Pediatrics 49(4):363-72. Apr 2010. DOI:10.1177/0009922809336206

2.) Dubins Rapid Interpretation of EKGs

P wave: Atrial depolarization. Represents the depolarization that spreads from the essay throughout the Atria.

PR segment: Reflects the time delay between Atria and ventricular activation

QRS complex: Ventricular depolarization. This is the largest wave because of ventricle contains the most muscle

ST segment: An interval between ventricular depolarization and repolarization

T wave: Ventricular repolarization. It's when the ventricular wall relaxes and recovers from the contraction.

Systematic Approach

 1.     Rhythm:

-        What is the rate?

-        P wave before every QRS

-        P wave should be + in lead II

2.     Axis Deviation: