Focused assessment of 3 yo in Respiratory Distress...

BeenThereDoneThat74, MSN, RN · May 29, 2005

I'm not a PICU conesseiur (?sp), but I float in occasionally. We had a mock code last week (really for the docs), and it was a similar scenario. Intubated kid getting worse. The answer was a pneumothorax. The residents were babbling something about the acronym DOPE (Dislodge, Obstuction, Pneumo, Equipment). I think that's what it stood for. I hope this helps.

The one thing I noticed anout the residents is that they didn't spend much time looking at the patioent. They were asking the attending about the #'s on the monitor. Not asking about pt's signs/symptoms.

Pediatric Critical Care Columnist · Jun 8, 2005

Focused respiratory assessment... that is an essential tool for PICU nurses. Children as a rule will stop breathing and THEN their hearts stop.

When you encounter a patient for the first time, you are already assessing them whether you realize it or not. It's called Primary Survey: what do you see and hear? The things you are observing instantly include the child's color (flushed, pale, cyanotic), and how hard they are working to breathe (head-bobbing, shoulder-shrugging, nasal flaring, stridor, gurgling, gasping, grunting, wheezing, coughing, rate and rhythm), and level of distress (is the child still crying? when they can't cry, you're in trouble) can be assessed while the child is still fully clothed. While you're getting the history from the mom (which will be a goldmine of clues at to what might be wrong), you're already assessing. Apply an oximetry probe somewhere on the patient so it can get warmed up while you move on to examination.

Auscultating the chest is part of your Secondary Survey. You want to listen for breath sounds over all fields. You're listening for air entry and adventitious sounds such as crackles, wheezes and stridor. Make mental notes of what your'e hearing while at the same time you're looking at accessory muscle use. There are a few common causes of respiratory distress in the child, including copious secretions (you'll hear them rattling around in the upper airways especially, often decrease or disappear with coughing or suctioning), foreign body aspiration (breath sounds may be wheezy or absent, particularly on the right [the right mainstem bronchus is proximal to the throat and is often the point of obstruction, but smaller items may move farther down the bronchial tree]), edema/inflammation (associated with asthma/reactive airway disease, bronchopulmonary dysplasia, infection [especially epiglottitis which is no longer common, but not gone]), "floppy" airways (associated with laryngo-, tracheo- and/or bronchomalacia, large tongue and decreased LOC) and congestive heart failure (fine crackles heard throughout the chest that don't clear with coughing or suctioning).

Part 2 of the Secondary Survey involves assessing rate and rhythm based on age and development. Tachypnea with irregular pauses is common. If there's a sudden decrease in the rate after a prolonged period of tachypnea, you're in trouble, as you are with a sudden cessation of effort. This is when intubation is imminent. While you're performing all these assessments there should be continuous oximetry; you may sense impending arrest by observing rapidly falling saturation coupled with the change in rate. Prepare to hand ventilate with a bag-valve-mask setup.

So now they're intubating your patient. It's always assumed in the ER that a patient has a full stomach and standard practice is rapid sequence intubation. Most physicians will want atropine given to help reduce secretions and decease the risk of bradycardia from vagal stimulation. Then you'd give a sedative, followed by a short-acting neuromuscular blocker such as succinylcholine. The airway will be suctioned and the vocal cords visualized, someone (usually the nurse if no RT is present) provides cricoid pressure to close off the esophagus, then the endotracheal tube will be placed. Immediately after the tube is placed you listen over both axillae for breath sounds. If you hear good breath sounds bilaterally, the tube can be taped in place. A chest x-ray will be needed to ascertain proper placement. What you'll do next depends on what is causing the child's problem. Albuterol and racemic epinephrine via nebulizer may be needed, and blood gases will be obtained. You will need to drop an NG to decompress the stomach. The airway may need to be suctioned. And you must observe for the return of spontaneous respiratory effort. Once the dust settles you chart. Ongoing assessment of air entry, breath sounds, saturations and blood gases will follow.

It is possible for all that I've outlined to take place in a period of minutes. The first time it happens to you, you will be very shaky, but that will pass. Good luck...

mitchsmom · Jun 17, 2005

janfrn... thanks for taking the time to write out that scenario... I'm sure it's all in my book but it's just not the same ... good reading for a student :)

Pediatric Critical Care Columnist · Jun 17, 2005

janfrn... thanks for taking the time to write out that scenario... I'm sure it's all in my book but it's just not the same ... good reading for a student :)

You're all welcome. As I said, for a PICU nurse, respiratory assessment skills are very important. I love the opportunity to share what I've learned with others.