Respiratory Distress in Infants

Building on my last post, I’ve found this youtube playlist of some short videos of infants in respiratory distress. From my year, so far(!), in Paeds ED, sepsis and respiratory problems have been the two most common medical reasons for admitting kids to PICU (ie the reasons why kids are big sick). And as winter comes round, there’ll be more and more bronchi kids

It’s really important to be able to recognise the seriously ill child, and if you can pick up on on these respiratory signs you’ll be doing pretty well. Before I add the links, just a quick point; we in the UK call the sucking in of various bits of the chest ‘recession’, but in the US they call it ‘retraction’.

So, here goes:

This is a really good example of ‘tracheal tug’; where there’s a big sucking in around the trachea. Really pronounced tracheal tug can be a sign of very severe respiratory distress. In adults with respiratory distress something you look for is someone who can’t speak in full sentences – this baby clearly cannot ‘speak’ in full sentences either.

In really small infants they ‘head bob’ because their neck extensor muscles are weaker than older kids.

This one’s particularly grim; it shows a small infant with horrendous sternal recession and tracheal tug. Sternal recession generally shows respiratory distress at a more advanced stage than intercostal and subcostal recession alone. These kids are often pretty sick. You can really hear the stridor as well

This video’s similarly unpleasant; it shows an older child with pretty much his whole chest sucking in (you can see this better at 00:14). This video appears to show the child being bagged.

None of these videos are particularly nice to watch, but they are very informative for any students doing paediatric placements.

And to make you feel better, here’s a video of a happy infant with puppies 🙂 

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Kids Can Go Downhill Very Quickly

A little while ago we had a little one come in who seemed unwell, but not horribly sick. She was only a couple of weeks old, but she was a bit snuffly and wasn’t feeding very well because she found it difficult to breath and feed at the same time.

We didn’t have any immediate concerns but were going to admit here to help with the feeding and give her a bit of a suction when we were free to clear her out.

An hour or so late, obs were done on the child and she was found to be in severe respiratory distress with sternal, subcostal and intercostal recession (see video below for an example), and oxygen saturations in the low 80s.

She didn’t respond to positive pressure, and when an infant of this age has to work so hard they tire quickly and their respiratory distress can turn into respiratory arrest. Before she got that point we had to assist her in her breathing by bagging her (using a bag valve mask) and then by breathing for her by intubation her. She was admitted to PICU and made a full recovery, but even so, to go from concern for feeding to severe respiratory distress in an hour without someone paying much attention is a little worrying.

Good on the parents for bringing this kid in. If they’d waited another few hours, the outcome could’ve been very different.

Winter is here

Winter has really kicked off in in paediatric a&e.

It’s still just about warm enough for kids to be out and about getting into accidents and being trauma called, but on top of that the winter wheezers are coming in too, and they’re pretty sick.

As ever, there’s a long wait to be triaged and having multiple kids sitting out waiting to be seen with their sats in their boots is not good.

The deluge has begun.

Cannulation

With all that goes on in A&E, cannulation doesn’t excite many people, but I find it really satisfying.

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Knowing that your efforts in getting a cannula in can make a big difference is someone’s life is a very rewarding feeling. Just today, my patients have been able to have medications for life-threatening conditions and strong pain relief because they were successfully cannulated 🙂

Hannah and her mum

Hannah had had a good day and was driving home with a smile on her face. Today she’d finalised the most time consuming contract of her fledgling legal career. She was planning her celebratory evening in her head when she felt her pocket vibrate, she looked down at her boyfriend’s text. This is where Hannah’s story ends.

About 90 minutes later Hannah’s mum walked into the hospital reception desperate for information. She’d raced to A&E after she’d received the call.

‘Hello, Mrs Green? I’m calling from the hospital, your daughter’s been involved in an accident and she’s had to be airlifted in. Please come as soon as you can.’

When she went to the reception desk, not wanting to be rude, she waited her turn. When she told the receptionist her story, his world weary expression softened and he walked her to the relatives’ room. After what seemed like an eternity there was a knock at the door and a little Indian man walked in. Mr Patel took the seat next to Mrs Green and began to talk, ‘Mrs Green, your daughter suffered extensive brain injuries and is very unwell, she’s going up to intensive care now, but I must warn you that she’s unlikely to wake up.’

Hannah’s mum’s face crumpled.

Winter in Paeds A&E

Is often unsafe.

We have enough money for the shifts, but they’re not being filled. From time to time we have had one nurse running the night shift. That nurse has to triage patients, observe patients and help doctors in treating them. So, when an emergency comes in, and the waiting room’s full, the waiting room has to wait. Or, we borrow nurses from the already hugely overstretched adult A&E; these nurses are excellent but they’re not paediatric nurses and so have not necessarily been trained in what to do if a very very sick five day old comes in.

Even when we are fully staffed we often don’t have enough space. If you have 50 patients come in three hours with only nine beds in the department…you do the maths. It don’t add up. That means patients having to be treated in areas away from monitoring equipment and not designed for patients to treated in.

How do we fix this? Train more nurses (Simple.) and keep them in the UK (Pay them more, and more nurses means better shift patterns … virtuous circle.).

Paeds Major Trauma

Generally isn’t that major.

The vast majority of incidents that trigger the ‘trauma tree’ in paediatrics are discharged within 24 hours.

The first paeds major trauma I saw sounded pretty serious on the way in: a hypotensive 12 year old boy involved in an RTC with part of his jaw missing. When he came in he was conscious, talking and haemodynamically stable…it turned out that the bit of his jaw missing was a couple of teeth. This boy had snapped the steel bar connecting the wing mirror to a minivan with his head and he had no brain bleed at all!

Other kids have fallen down tens of stairs and seemingly just bounced. Because of the mechanism of injury they are classified as ‘major trauma’ but many of these kids don’t have a scratch on them!

Even the girl who had to be intubated and sent to neurointensive care after a very high speed car accident was discharged four days later.

Saying that, whenever the ‘blue call’ alarm goes off in A&E I still stop talking to find out if it’s for us.