P U E B L O C O U N T Y M E D I C A L T R E A T M E N T P R O T O C O L S PEDIATRIC RESP DISTRESS U P D A T E D : 3 / 0 8 / 2 0 1 2 W E B E R , M D D . W I L S O N , M D Specific information needed 1. Present symptoms -- sudden or gradual onset. 2. History of oral exposures -- toys, food, chemicals, etc. 3. Associated symptoms -- cough, fever, upper respiratory symptoms, runny nose,
4. Past medical problems. 5. Current medications. Specific objective findings 1. Mental status -- alert, agitated, confused, somnolent. 2. Respiratory effort -- upper airway sounds, chest wall movement, use of accessory
muscles, retractions (depressions between ribs on inspiration).
3. Audible breathing noise -- wheezes, cough, stridor. 4. Lungs by auscultation -- wheezes, crackles (wet sounds), clear lung fields,
5. Other findings -- drooling, fever, skin color. Treatment
1. Put patient in position of comfort (usually upright). 2. If respiratory arrest -- attempt to ventilate. Watch neck position carefully and
3. If patient has airway obstruction from foreign body:
a. Encourage coughing efforts with partial obstruction. b. If no air movement, visualize airway with laryngoscope and remove any
c. Reposition the airway. d. Attempt to ventilate. e. If unsuccessful, administer up to 5 subdiaphragmatic abdominal thrusts
for children or 5 back blows and 5 chest thrusts for infants.
f. Reposition the airway and attempt to ventilate. g. If unsuccessful, consider percutaneous cricothyrotomy with 14 g.
4. Apply O2, high flow (10-15 L/min or volume sufficient to keep bag inflated) for
significant respiratory distress. Titrate to pulse oximetry > 90% if possible.
5. If patient is ventilating inadequately:
a. Assist ventilations as needed with bag-valve-mask and high flow
b. Consider intubation if less invasive means are inadequate.
6. Assist and consider treatment for the following problems if respiratory distress
is severe and patient does not respond to proper positioning and administration of O2:
i. Prepare to assist ventilations if child fatigues and is unable to
P U E B L O C O U N T Y M E D I C A L T R E A T M E N T P R O T O C O L S PEDIATRIC RESP DISTRESS U P D A T E D : 3 / 0 8 / 2 0 1 2 W E B E R , M D D . W I L S O N , M D
iii. Assist with removal of secretions if needed.
iv. Administer albuterol via nebulizer (see albuterol protocol).
v. Consider nebulized saline as another treatment option.
i. Administer albuterol via nebulizer (see albuterol protocol).
ii. Administer SQ epinephrine if no improvement with albuterol
7. If diagnosis is unclear, transport patient rapidly with supplemental O2, and
prepare to assist ventilations if child becomes fatigued or sustains respiratory arrest.
Specific precautions 1. Children with croup, epiglottitis or laryngeal edema usually have respiratory arrest
due to exhaustion or spasm. They may still be ventilated with pocket mask or bag-valve-mask (BVM) technique. Don't attempt intubation unless these techniques fail.
2. Intubation of children in the field is infrequently performed, and therefore carries
some risk. Do not attempt intubation if a simpler skill will manage the airway.
3. Bag-valve-mask in small children carries the risk of excessive pressures and
possible pneumothorax. It is easy to get overly excited and over-ventilate.
4. In respiratory distress of sudden onset, think of foreign body aspiration. The
mouth is a major sensory organ for children (as well as others) and admits a multitude of obstructive hazards.
5. There may be a call to attend a child who has allegedly aspirated something that was in
his or her mouth, but is now asymptomatic. This child may not need emergency intervention, but should be seen by a physician. Once the object has settled in the lung and is not irritating a major airway, it can rapidly become asymptomatic while still requiring removal to prevent further complications.
Invasive Plants Of Tennessee December 2009 (2nd Edition) The purpose of this list is to identify introduced plant species that are invasive or may becomeinvasive and cause damage to native plant communities. Introduced species are plants not native toa region of the state and are referred to as exotics. The intent of this list is to:• rank exotics based on their invasive characteristics;•