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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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.