# 7 yo SOB



## Angel (Feb 7, 2014)

Dispatched at 0245 to a single family dwelling for a 7 yo having difficulty breathing. Fire arrives shortly before you do and states (per family) pt woke up out of his sleep due to SOB, has a history of asthma and parents tried an albuterol treatment with no relief and decided to called 911. Other hx unknown because these are his ADOPTIVE parents.

Kid is tripoding and you hear wheezes in all fields. skin in Pink, warm and dry, no accessory muscle use that you can see, RR 36, BP 110/60, P too fast to count

What do you want next? Engine has 3 people, Medic has you and your partner.


----------



## NJEMT95 (Feb 7, 2014)

What's his O2 saturation? Assuming it's diminished, as BLS, I'll call for ALS and start him on O2 via NRB (NC if the mask causes him more anxiety). Try to keep him as calm as possible and get to the closest peds ER.


----------



## Handsome Robb (Feb 7, 2014)

That respiratory rate is high for a 7 year old. I'm a medic so I'm going to use the monitor to get a pulse rate, spo2 would be nice but not the end all be all. I would like to have a room air SpO2 if it's  at all possible. If we've got it xopenex wouldn't be a bad option since he already is really tachy. Even then he's 7 and peds are respiratory driven so I'll settle for some tachycardia if it means better ventilation and oxygenation. Might consider a duoneb if that's not helping. 

Been sick at all recently? Any complaints? Ever been hospitalized for asthma in the past? Ever been intubated before? Ever been on CPAP?  Is his asthma well controlled?


----------



## Angel (Feb 7, 2014)

room sp02 was 92 increased to 95 on NRB @ 15L

@NJEMT95 what do you think is going on with him? ALS is en route ETA of 5 mins

monitor shows sinus tach @184, room sat is 92 and increases to 95 on NRB (as above)
no relief with the xopenx or duoneb, HR increases to 192, RR 40

family denies recent illness, dad says they were at the lake earlier that day with no complaints, not sure if hes ever been intubated or put on CPAP but they don't think so. NKDA and only meds is the albuterol

 upon loading in the rig the kid starts to cough and you check breath sounds in his neck, you hear a very FAINT squeal. Pt is NOT yet lethargic but unable to speak. he answers your questions with a thumbs up/down.

Do you want to bring a rider? Bring parent?

You transport code 3 to the ER with an ETA of 7 minutes

What else do you want to do?


----------



## NomadicMedic (Feb 7, 2014)

I missed the hr. Transport.


----------



## vc85 (Feb 7, 2014)

BLS here:

O2 NRB, Administer nebulized albuterol.  If asthma is still refractory call med control for an epi-pen order.  Rapid tcp


----------



## exodus (Feb 7, 2014)

Put him on capnography and see what you're dealing with.


----------



## Angel (Feb 7, 2014)

he is hyperventilating so etco2 is low (I didn't get a #) so lets say 30
waves are consistent with this.

Pt has persistent wheezes do you want to keep repeating the neb tx en route?
what about IV or other meds?

@vc85, med control gives permission for the epi, you verify and give IM with no changes

eta at this point is 3 minutes

As far as ddx what are you guys thinking?

any other info you want?

For the BLS guys, would you consider him in resp distress or failure? why?
would you consider PPV? 

ill let it play out a little longer then tell you all what I did and what the hosp diagnosed him with.


----------



## exodus (Feb 7, 2014)

Waves are consistent with what? What does the waveform look like?   shark fin, boxy, what?


----------



## Angel (Feb 7, 2014)

like this, I cant get it any bigger though



source: http://12leadekg.wordpress.com/2011/02/08/lets-talk-capnography/


----------



## exodus (Feb 7, 2014)

12 lead?  With the waveform looking like that, I would think something cardiac related. Or upper airway, croup?


----------



## NJEMT95 (Feb 7, 2014)

At this point, I'd still consider this respiratory distress, but nearing failure. Since they were at the lake earlier, there's a chance of this being 'dry drowning.'


----------



## AnthonyTheEmt (Feb 7, 2014)

exodus said:


> 12 lead?  With the waveform looking like that, I would think something cardiac related. Or upper airway, croup?



Are you really gonna do a 12-lead on a  7 year old?:unsure:


----------



## Handsome Robb (Feb 8, 2014)

His etco2 should be high, since he's air trapping. Right? 

If I have to give him Epi I will but with a rate that high you're starting to need to pay attention to it. That's SVT parameters in his age group. Iatrogenic SVT is my opinion but that's all it is, an opinion.

Mag drip, IV steroids if we're continuing down asthma/RAD.

I have a question though, you described a "squeal" and his etco2 waveform isn't really all that constrictive. I might have asked and missed the answer but febrile? Drooling? Angioedema? 

Epiglottis is a very real possibility, what'd this cough sound like? It could be croup but the acute onset doesn't support it. Nebulized Racemic Epinephrine  could be an option and I'm honestly wondering if the asthma Hx got a tunnel vision out of us

Regarding 12-leads in kids, unfortunately this nation doesn't screen children well for cardiac defects. School aged children and teens die every year secondary to an unrecognized congenital condition. Now with a rate of 190+ there's no point, but we do need to consider a cardiac etiology. I just toyed with a scenario that a friend ran somewhere else with a 4 year old female in a 3AVB at 60 with a UTI...

Did he have an incident at the lake? Dry drowning is a good thought but he'd have to have had a near drowning incident.

I'd call this distress vs failure. 

Asthma/RAD
Croup/Epiglotitis
Cardiac


----------



## exodus (Feb 8, 2014)

AnthonyTheEmt said:


> Are you really gonna do a 12-lead on a  7 year old?:unsure:



Give me a good reason I wouldn't other than how fast the HR is.


----------



## vc85 (Feb 8, 2014)

With an ETA of three minutes, rapid transport (our als is usually 10 to 15 away, at least).  Consider BVM if sat's start to drop or signs of poor 02 perfusion


----------



## Carlos Danger (Feb 8, 2014)

exodus said:


> Give me a good reason I wouldn't other than how fast the HR is.



How about the fact that you have a respiratory emergency to deal with, which takes precedence over the performance of diagnostic tests that are very unlikely to provide clinically useful information?


----------



## Carlos Danger (Feb 8, 2014)

The possibilities here are numerous. Not enough info to make a dx.

Based on what is provided, I'd say moderate-severe asthma attack vs. mild-moderate asthma attack exacerbated by anxiety.

Continued nebs + 02 + transport in position of comfort. Perhaps a smidge of Ativan if you begin to strongly suspect an anxiety component. Which is where I would lean based on the low Etco2.

Epi + mag + ketamine if he worsens. 

If he worsens still, CPAP trial +/- intubation by the most experienced intubator in the land.

Obviously needs a CXR and ABG upon arrival at the ED.


----------



## exodus (Feb 8, 2014)

Halothane said:


> How about the fact that you have a respiratory emergency to deal with, which takes precedence over the performance of diagnostic tests that are very unlikely to provide clinically useful information?



So taking 10 seconds for the monitor to capture a 12 lead is too much time? You have usually 5-6 people on scene, it takes about 30 seconds to setup a 12 lead and 10 to capture. This is very well may be a cardiac event.  If we have an adult with SOB not relieved by duoneb, are you not going to do a 12 lead on them?

I got a feeling we're looking for zebras here and the wheezing is potentially coming from upper airway and the kid ate a dog toy or something.  Or it's just a dry drowning, but if it's a fresh water lake, how well are the chances of that?


----------



## mycrofft (Feb 8, 2014)

Failed to get respiratory response to earlier albuterol but he did get tachy. More albuterol likely to do same, but heart rate even faster.

I am reading wheezes are heard, then a "faint squeak". Are we talking about stridor or wheezes here (hear)?

Is the pt getting worse better or same?

Ausc airway starting at upper throat through larynx and to manubrium, then  each side. Might find a mayfly or a willow leaf? Either way, if it isn't causing a crash and hospital is close, just go there and let them get a film.

Ask Dad if kid puts stuff in mouth?

PS: parents smoke, or smoke crack?


----------



## Imacho (Feb 8, 2014)

Sounds like croup. Racemic Epi.


----------



## Angel (Feb 8, 2014)

Ok so you arrive at the ER and a nurse is waiting for you to take him into a room

Skip to the bottom to read what happens next



Robb said:


> His etco2 should be high, since he's air trapping. Right?
> 
> If I have to give him Epi I will but with a rate that high you're starting to need to pay attention to it. That's SVT parameters in his age group. Iatrogenic SVT is my opinion but that's all it is, an opinion.
> 
> ...



The lake bit had no significance except to say that it was an acute onset of severe resp distress.

Here's how I ran it:
continued him on albuterol tx (for the wheezes) and kept them going the entire ride over, then came epi, an IV (got at 24g which slipped right out so I had to poke the poor kid again), ecg, 4 lead not 12, at no point did I think it was cardiac so I never got a 12 lead, I cant say it is right or wrong to do one (especially since here we can only technically do them if treating cardiac chest pain) but more information, if there is time, wont hurt. 

for us CPAP is contraindicated for peds 

I took dad on the txp and he remained calm and I think that help the son.


as soon as we got to his room at the ER the doc said "sounds croupy to me"
he got racemic epi and by the time I finished my tag he was completely back to normal. 

.... something ill never forget, not all croup literally "barks"

IF you all have and are able to use racemic epi then it totally helped in his case so good job for suspecting croup


----------



## mycrofft (Feb 8, 2014)

Thanks for the thread! (PS I sent a reply, it failed to post, so if it appears later, I'm sorry).

Epi in croup in a 7 y/o? Ok. Don't forget Calif had its first kid die of pertussis recently, too.

Hey,no one asked if anyone at his school ate peanutbutter sandwiches!


----------



## Angel (Feb 8, 2014)

thanks, kids always keep us on our toes


----------



## Carlos Danger (Feb 8, 2014)

exodus said:


> So taking 10 seconds for the monitor to capture a 12 lead is too much time? You have usually 5-6 people on scene, it takes about 30 seconds to setup a 12 lead and 10 to capture. *This is very well may be a cardiac event.*  If we have an adult with SOB not relieved by duoneb, are you not going to do a 12 lead on them?
> 
> I got a feeling we're looking for zebras here and the wheezing is potentially coming from upper airway and the kid ate a dog toy or something.  Or it's just a dry drowning, but if it's a fresh water lake, how well are the chances of that?



In a 7 year old whose only history is asthma, a presentation of respiratory distress with wheezing is so unlikely to be an ischemic cardiac event (or anything else that would change your plan of care) that I would go so far as to say a 12-lead is absolutely contraindicated. Your protocols may say different, of course, but protocols are designed largely to CYA.

As far as "dry drowning" goes, that simply means that the initial aspiration of water caused a laryngospasm that prevented a larger volume of water from entering the lungs. This is actually how a majority of drownings occur. It has nothing to do with fresh vs. salt water.

Where I've worked, I almost never had 5-6 people on scene, FWIW. Not ones that I would allow to participate in patient care, anyway.


----------



## teedubbyaw (Feb 8, 2014)

Thanks for the post and sharing the outcome. Good info!


----------



## mycrofft (Feb 9, 2014)

*Hey! Hey!*



Imacho said:


> Sounds like croup. Racemic Epi.







IMACHO wins the chicken dinner!!


----------



## Handsome Robb (Feb 9, 2014)

Cool thread thank you!

The seal bark cough is unmistakable once you've heard it once. Racemic Epi is awesome too. Had kids that scared me only to get to the ER and the doc is like "why did you bring them here?"


----------



## teedubbyaw (Feb 9, 2014)

Does anyone actually have protocols for nebulized epi in the field?


----------



## NomadicMedic (Feb 9, 2014)

teedubbyaw said:


> Does anyone actually have protocols for nebulized epi in the field?




We do. (I actually posted nebbed Epi way back in the beginning of this thread, second guessed myself  based on HR and the vague description and edited it. Oh well)


----------



## Imacho (Feb 9, 2014)

mycrofft said:


> IMACHO wins the chicken dinner!!



Boo ya!!! Ha a pt almost exactly like described. Only he was 3. First time using the racemic Epi. Standard protocols. It was epic to see the great improvement. Mom was with us and almost started crying cause she was so happy to see her son doing better. That's why I love being a medic.


----------



## mycrofft (Feb 9, 2014)

In my day, we had a few. Always calls at night and the winter (in Nebraska). We would roll down the window and the symptoms often abated.


----------



## Handsome Robb (Feb 9, 2014)

teedubbyaw said:


> Does anyone actually have protocols for nebulized epi in the field?




We do nebulized Racemic Epi on standing orders. Not straight Epi though.


----------



## Sublime (Feb 9, 2014)

My protocols allow me to nebulize 0.3mg of epi 1:10000


----------



## Milla3P (Feb 10, 2014)

It's February. He has the croup. Give him humidified oxygen. Take him to an EMERGENCY ROOM!!! If he has a PMHx of asthma give him a "nebby". If he has a Hx in ambulances he'll be fine with it, if he fights it it's not worth it. If it's not croup it's acute bronchospasm and the sympathometic will resolve the problem. He clearly needs to go to the hospital. Talk to the parents and scold them for not calling his PCP sooner. Realize that we just need to shuffle people around.


----------



## bmedic1681 (Mar 13, 2014)

Albeuterol 2.5 and atrovent 0.25, cardiac monitor, IV normal saline KVO or NS lock. if the wheezing remains neb treatment as needed secondary albuterol at 2.5mg and prednisone at 1-2mg/kg PO… if the pt did not respond to this and BP is less than 90mmHg and less than 8 years old Mag sulfate at 40-45mg/kg in 100 ML of saline over 20 min with max dose of 2.0…. if all this fails and since my pt is 7 with a HR of less than 180bpm I would give EPI (1:1000) 0.01mg/kg IM with a max dose of 0.3mg


----------



## bmedic1681 (Mar 13, 2014)

(It's February. He has the croup. Give him humidified oxygen. Take him to an EMERGENCY ROOM!!! If he has a PMHx of asthma give him a "nebby". If he has a Hx in ambulances he'll be fine with it, if he fights it it's not worth it. If it's not croup it's acute bronchospasm and the sympathometic will resolve the problem. He clearly needs to go to the hospital. Talk to the parents and scold them for not calling his PCP sooner. Realize that we just need to shuffle people around.)

THERE WAS NOTHING MENTIONED ABOUT A SEAL LIKE BARK OR COUGH and typically croup is from infancy to 5 years old…. 7 is a tad to old typically...


----------



## bmedic1681 (Mar 13, 2014)

Peanut allergies this far along would show difficulty swallowing and breathing…. GEEZ HX of asthma….. status asthmaticus people


----------



## bmedic1681 (Mar 13, 2014)

OK a squeal like sound aka wheeze…. musical sound is a wheeze…… seal like rough bark or cough is indicative of croup


----------



## bmedic1681 (Mar 13, 2014)

as for the person who questioned cardiac monitor on a child….. HAVE you ever seen a child compensate to the point of arrest?????? I HAVE


----------



## bmedic1681 (Mar 13, 2014)

error in post


----------



## Handsome Robb (Mar 13, 2014)

I'm pretty sure we established this was croup after the OP followed up...maybe some poor wording on the description of the  sound.


----------



## bmedic1681 (Mar 14, 2014)

I would have to agree wording is inaccurate having had a child with croup you don't EVER forget the sound, it is rough and harsh however based on the description I am surprised more people did not say pertussis (whooping cough) which is often mistaken as croup…. Just glad the child is ok….. however my treatment would have stood fast as this child was in distress with sats as low as they were


----------



## Household6 (Mar 14, 2014)

Since you're here Robb... Do you see alot (or any) epiglottis? In the cases you have seen, are the patients UTD on the recommended vaccination schedule?


----------



## Handsome Robb (Jan 30, 2015)

Household6 said:


> Since you're here Robb... Do you see alot (or any) epiglottis? In the cases you have seen, are the patients UTD on the recommended vaccination schedule?



I totally missed this, was looking for scenarios for my trainee and found it.

All the epiglotitis patients I've had have been in their 20s or 70s. Not super common but I've had a few.


----------

