COMA IN PEDIATRICS!

*STATE OF UNRESPONSIVENESS DUE TO DIFFUSE LESIONS OF HEMISPHERES / BRAIN STEMS: 1.Structural lesions bleeding, tumour, abscess, hydrocephalus
2. Non-structural lesions (95%) seizures, drugs / poisons infection (meningitis, encephalitis, HUS) metabolic (hypoglycaemia, DKA, Reye) renal failure, hepatic coma endocrine (Addison)

*ASSESSMENT AND DIAGNOSIS:
 1.Rapid History and General Examination:
 Skin (trauma, petechiae, bleeding)
 Sutures in infant and neck stiffness, systemic, AF 
2.CNS examination:
 GCS, Gag R, Blinking
 Pupils Reaction, EOM Palsy, Fundi, Dolls Eye
 Motor- Posture, Tone, Symmetry/Lateralizing signs
 Reflexes- DTR, Plantars
 Pain, Grimace, Flexion, Extension, None
 Assess level of Central Dysfunction

CRITICAL CARE PEARLS OF UPPER AIRWAY OBSTRUCTION !

Critical Care Pearls
• Upper airway obstruction (UAO) is a life-threatening emergency that requires prompt
diagnosis and treatment.
• Severe UAO can be surprisingly asymptomatic at rest if it develops gradually. Sudden
clinical deterioration is unpredictable.
• Patients with possible UAO must never be sedated until the airway is secured. Minimal
sedation may precipitate acute respiratory failure.
• Achievement of airway patency in total airway obstruction and reestablishment of ventilatory airflow is the first and foremost goal of the treating physicians.
• Critical care physicians must be aware that pharmacologic interventions (epinephrine,
steroids, and heliox) provide temporary support but cannot significantly improve
mechanical UAO.
• Bronchoscopy constitutes the most accurate diagnostic tool and frequently provides the
best way to correct UAO.
• Cricothyroidotomy is the surgical intervention of choice to reestablish airflow when
medical interventions have failed.


Clinical Signs and Symptoms:
*In a conscious patient,
 signs and symptoms of  UAO include
1. marked respiratory distress,
2.altered voice
3. dysphagia
4. odynophagia
5. the hand-to-the-throat choking sign
6. stridor
7. facial swelling
8. prominence of neck veins
9. absence of air entry into the chest
10. tachycardia

*In an unconscious or sedated patient,
1. the first sign of
airway obstruction may be inability to ventilate
with a bag-valve mask after an attempt to open
the airway with a jaw-thrust maneuver.
2. After a few minutes of complete airway obstruction,
asphyxiation progresses to cyanosis, bradycardia, hypotension, and irreversible cardiovascular collapse.

Exams &  Investigations:

A.Physical examination may show:

• Decreased breath sounds in the lungs
• Rapid, shallow, or slowed breathing

B.Investigations:
1.Plain Chest and Neck Radiographs.
2.Spirometry
3.Bronchoscopy
4.Computed Tomography
5.LARYNGOSCOPY

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common emergencies of upper airway in adults

• Upper airway obstruction

• A foreign body (Latin: corpus alienum) is any object originating outside the body. In machinery, it can mean any unwanted intruding object.  
•    Epiglottitis is an inflammation of the epiglottis — the flap at the base of the tongue that keeps food from going into the trachea (windpipe). Due to its place in the airway, swelling of this structure can interfere with breathing, and constitutes a medical emergency. Infection can cause the epiglottis to obstruct or completely close off the windpipe.
• Croup (or laryngotracheobronchitis) is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, andhoarsene 
•  Allergic reactions in which the trachea or throat swell closed, including allergic reactions to a bee sting, peanuts, antibiotics (penicillin), and blood pressure medications (ACE inhibitors)
• Chemical burns and reactions
• Croup
• Epiglottitis (infection of the structure separating the trachea from the esophagus)
• Fire or burns from breathing in smoke
• Foreign bodies -- such as peanuts and other breathed-in foods, pieces of a balloon, buttons, coins, and small toys
• Viral or bacteria infections
• Peritonsillar abscess
• Retropharyngeal abscess
• Throat cancer
• Trauma
• Vocal cord problems
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AIRWAY EMERGENCIES!

Airway Emergencies
By Donald R. Elton, MD, FCCP
Lexington Pulmonary and Critical Care
Introduction 
The airway, consisting either of natural anatomy or a plastic tube, is arguably the most important part of the pulmonary system. Without an adequate airway, the remainder of the cardiopulmonary system is of little value. Because of this importance, loss of patency becomes the most urgent emergency that can be imagined in medicine. Rapid accurate recognition and treatment of airway emergencies are essential to the provision of emergency and critical care medicine. Anatomy 
The natural human airway consists of the nasopharynx and oropharynx, the larynx, and the trachea. Most airway emergencies result from obstruction to airflow. Obstruction can result from internal obstruction either by edema, spasm, or a foreign body, or from external compression or distortion. Airway obstructions can be congenital or acquired. Examples of congenital airway obstructions are tracheal atresia, laryngeal web, choanal atresia, and vascular ring with tracheal compression. These congenital obstructions, if severe enough, can result in death in the delivery room if immediate surgical intervention is not provided.  Foreign Body Aspiration 
Foreign body aspiration normally occurs during eating, particularly when the patient has an impaired gag reflex such as might be caused by consuming alcohol or by anatomical neurological deficits as might be seen following a stroke. With a complete obstruction, there is no sound of air movement audible at the mouth and the patient is unable to speak. Sternal, suprasternal, costal, and infracostal retractions are also common in upper airway obstruction as is a piston-like motion of the trachea as seen in the neck with inspiratory efforts. Of course, these findings are very temporary if the obstruction is not treated so airway obstruction must be assumed to exist in any apneic patient until proven otherwise. Treatment consists of either removing the obstruction via the fingers or instruments (forceps and laryngoscope for example) or by moving the obstruction below the level of the carina such that a complete obstruction only blocks ventilation to one lung. Complete obstruction can also be treated by bypassing the obstruction with a tracheotomy or cricothyrotomy. Some obstructions will require urgent bronchoscopy and the use of a rigid scope, if available, may be more successful given the larger channel size. The Heimlich maneuver may also be used when other more definitive methods are not immediately available. In cases of partial obstruction, one must be careful not to convert the situation to a complete obstruction and the urgency of treatment must be titrated to the degree of obstruction with severe partial obstructions being treated like complete obstructions. One seldom available technique for buying time in cases of partial airway obstruction is the use of a helium-oxygen mixture since the helium has a lower density than nitrogen and thus can ventilate a patient with less pressure required. If a patient must be ventilated past a partial airway obstruction, the ventilation should be provided by a manual resuscitator instead of a mechanical ventilator and slow deep breaths should be delivered with attention given to providing adequate expiratory time. Using a manual resuscitator allows for immediate detection of changes in airway resistance and will tend to do a better job of ventilating the patient.  Angioedema
Angioedema is an allergic type reaction that results in any combination of lip, face, neck, tongue, uvula, palate, epiglootic, glottic, and tracheal edema. The most common causes are drugs (particular ACE inhibitors - angiotensin converting enzyme inhibitor antihypertensive medications like Vasotec (enalapril), Capoten (captopril) and others). Other causes include various foods (commonly shellfish), and an ideopathic form (hereditary angioedema). This problem is a little tricky as it may occur after months or even years of incident free use of ACE inhibitor drugs. Most cases present with painless lip swelling, sometimes one, sometimes both. Symptoms increase if exposure to the offending agent continues and this is common since the cause is frequently unsuspected by the patient since it may not be a new exposure. If there is swelling of anything inside the mouth or throat then airway obstruction can occur leading to death. Intubation via the oral route is frequently impossible and may be difficult via the nasal route as well. Once airway obstruction has reached a critical stage, manipulation of the airway could lead to worsening edema and lead to complete obstruction. Ideally a patient with angioedema should be intubated in the operating room with someone ready to perform an emergent tracheotomy or cricothyrotomy if needed. Patients with swelling of the lip, uvual, or who already have respiratory compromise need admission and anyone who has difficulty breathing, swallowing, or speaking should have an airway secured as soon as safely feasible. Other treatments include subcutaneous epinephrine (when not otherwise contraindicated), steroids, Benadryl (diphenhydramine), and histamine blocker anti-acid medications like Tagamet (cimetidine) etc. Recovery usually occurs within a few days provided the causative substance is removed. Infectious airway obstruction 
The two most common infectious causes of airway obstruction are laryngotracheobronchitis (croup) and epiglottitis. Both are more common in children but both can occur in adults. Croup is usually a viral illness that results in subglottic (tracheal) stenosis.. The onset is usually over 4-5 days at the end of an upper respiratory infection. Croup does not usually become life threatening but it can be if severe. Diagnosis can be made by a PA soft tissue neck x-ray which will show tracheal narrowing at the top of the tracheal air shadow (steeple sign). Patients with croup have a variable amount of respiratory distress and have a peculiar barking cough (at least infants do). Croup is normally treated with cool mist and sometimes steroids and/or aerosolized racemic epinephrine which acts as a topical vasoconstrictor. The most important thing to remember with croup is that you must be sure that the patient doesn't really have epiglottitis which is usually a more serious condition. Epiglottis usually results from a bacterial infection, frequently Haemophilus influenzae. The onset is rapid and can progress to severe airway obstruction within 6-8 hours in infants though usually it takes longer in adults. Stridor, dysphagia, odynophagia, and drooling (from inability to swallow) are typical symptoms. Patients with epiglottitis tend to be very anxious (not to mention their doctors). A lateral soft tissue neck x-ray is usually diagnostic but if obstruction is severe the patient should probably proceed to the operating suite for a controlled intubation by the most experienced person available rather than risking a complete airway obstruction in the radiology department. Laryngoscopy should ideally not be attempted unless personnel and equipment for an emergent tracheotomy is available. An abscess can also obstruct the upper airway. Symptoms may vary depending on the location but are usually similar to those of epiglottitis. Again, a lateral soft-tissue neck x-ray is helpful for diagnosis and a CT scan is useful if the airway can be protected. Airway Trauma 
Airway trauma can result from either blunt or penetrating injuries. Blunt trauma can cause a collapse of the trachea with intraluminal obstruction from the extrinsic pressure or there can be disruption of the trachea or major bronchi resulting in air leaks. Air leaks from the major airways can result in soft tissue and subcutaneous emphysema which can either be benign or can compress the airway or cause a pneumothorax or pneumomediastinum. If the history of injury suggests blunt or penetrating trauma to the chest or neck, then the soft tissues should be palpated for deformities or subcutaneous air and x-rays should be obtained to look for evidence of air leaks. Positive pressure applied to the airway should be avoided if possible or at least minimized to prevent the extension of air leaks that might otherwise be self limited.  Artificial airway emergencies 
Artificial airways are normally tracheostomy tubes, and oral/nasal endotracheal tubes. Other airways would be tracheal buttons and the like. It is important that physicians caring for patients with artificial airways be very familiar with the construction and proper use of those airways as improper use can be life threatening. For example, it's a bad idea to inflate the cuff of a fenestrated tracheostomy tube when you have both the external and internal lumens occluded. Endotracheal tubes can become obstructed with mucus, particularly in cases where the mucus contains blood, secretions are thick, humidification is inadequate, and/or airways are small in diameter or have sharp bends that narrow the lumen. It is possible to have an endotracheal tube totally obstructed by mucus that a patient cannot breath around and yet be able to pass a section catheter through the viscid obstruction. Sometimes a partial obstruction of an endotracheal tube will cause musical breath sounds over the trachea. In mechanically ventilated patients you might note adequate breath sounds for mechanical breaths (albeit with high peak pressures) but note no air movement with weaker spontaneous efforts. If there is any doubt of airway patency then the airway should be replaced immediately. It is possible for an airway cuff, if overinflated or defective, to herniate over the end of the tube resulting in partial or total airway obstruction. If this happens the airway should be replaced as a cuff deformed in this way may be more likely to herniate again. Cuff trauma to the tracheal mucosa can result in edema and/or fibrotic scarring that will obstruct the trachea upon extubation. This will not usually be suspected until the patient develops respiratory distress upon extubation. For this reason, patients should never be extubated unless someone is present who can immediately reinsert an endotracheal tube, perhaps of a smaller diameter than the one removed. With longer term intubation, it is possible for a cuff to erode through the tracheal wall and into blood vessels. This is less common today with lower pressure cuffs but can still happen. Usually airway obstruction secondary to the bleeding is more important than the amount of blood loss so the initial goal of therapy is to protect the airway, usually by inserting the tube beyond the point of bleeding and inflating the cuff. Elevating the head of the bed will reduce the blood pressure in the bleeding vessel until surgical assistance is available. Cuffs that won't hold their air pressure usually result from leaks somewhere between the cuff itself and the syringe adapter. Cuffs frequently can be torn by teeth or nasal bones and tubes have to be replaced when this happens. If the leak is in the pilot line valve (where the syringe attaches) or the pilot line is accidentally cut you can try inserting a stop-cock where the syringe goes or alternatively can cut the pilot line and insert a blunt needle with a stop-cock attached to replace the valve that came with the tube.Accidental Extubation 
This can be an emergency if there is difficulty replacing the airway or if it just isn't detected in a reasonable amount of time. Everyone knows to listen for breath sounds to verify an endotracheal tube's position but many don't realize that you can get pretty good breath sounds with the endotracheal tube cuff above the vocal cords or even in the esophagus. Two fairly reliable signs of an extubated patient are the patient's ability to speak or large leaks of ventilator breaths around a properly inflated tube. One quick reliable method of verifying that a tube is in the trachea is to just use a laryngoscope to look at the tube going beyond the cords. An alternative but less desirable method is to get a PA and lateral chest x-ray. The lateral is most important as the trachea is an anterior structure while the esophagus is posterior. In the patient with a tracheostomy, particularly a fresh tracheostomy, there is a possibility that it will be difficult to find the stoma in the neck through which to replace an accidentally removed tube. Remember that most such patients still have lips through which you can pass an oral tracheal tube in an emergency. Also, remember that you can always use a plain endotracheal tube to replace a tracheostomy tube in cases where the proper size tracheostomy tube isn't available or where the upper airway has been damaged by trauma, infection, or is bleeding. Several years ago I saw a patient who had fallen on a running chain saw and had severed his trachea and esophagus. A paramedic at the scene saved his life by intubating the free end of his trachea with an endotracheal tube.  References 
Elton DR, Berkowitz GP: Endotracheal tube obstruction in neonates, Perinatology-Neonatology, 5:5, pp 75-80, 1981. 
Shapiro BA, Harrison RA, Trout CA: Airway care in Clinical Application of Respiratory Care, , 2nd ed., Year Book Medical Publishers, 1979. 
Rowe LD: Otolaryngology in Way LW: Current Surgical Diagnosis & Treatment, Lange Medical Publications, 1981. 
Don Elton delton@cts.com Columbia, South Carolina