# Difficulty breathing scenario



## orange20medic (Apr 3, 2011)

I ran this and was surprised at the outcome of it.

Our station got dispatched for an Echo response (top priority) for a 6 yo female respiratory distress, possible respiratory arrest. ALS unit went enroute. I was on a BLS unit and was approximately 10 minutes out. We heard medics calling on scene for assistance to go to the LZ, so we went. Pt was 6 yo female who had been sick for approx. 1 day. Pt has no medical history. She was running a fever, so her doctor told her parents to put her in the bathroom with a steam bath. Upon doing this, pt began experiencing extreme difficulty breathing and EMS was called. Upon ALS arrival, pt was breathing approx. 34-36 times a minute and a "crowing" noise was heard upon expiration. When asked if she was having trouble breathing, pt shook her head No. Pt was given 15L O2 non rebreather and was also given albuterol. IV was initiated and fluid run. Medics could not figure out what was wrong with her so they waited for the flight nurse to come on board before pushing meds. Flight nurse and medic also did not know what was wrong with her. Flew pt to children's hospital.

So... what are your thoughts as to what was wrong and how would you have handled this situation?


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## MrBrown (Apr 3, 2011)

What do you mean by "crowing" noise? 

Lung sounds? work of breathing? accessory muscle use? SPO2? evidence of hypoxaemia? 

Brown is thinking could be epiglotitis or croup

How are were you from the hospital? Seems a bit of overkill to send HEMS.


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## orange20medic (Apr 3, 2011)

We were over an hour out of children's hospital. Our "local" hospital is 25 minutes away and won't take Peds. Another reason we called HEMS was because they run a nurse on the bird. The nurses can give more meds and treatments in a situation like this.

Lung sounds were clear. The crowing noise sounded upper airway. Just picture a bird crowing. It's what it sounded like. There was minor accessory muscle use. SPO2 was 95% before O2 was applied. 100% after the O2 and albuterol. And there were no signs of hypoxemia. Her parents had also given her benadryl earlier in the day (it was 2200 when we got called) and parents thought maybe she was sick from allergies as it was allergy season. 

When we followed up on the patient, Children's hospital diagnosed her with a severe case of epiglottitis. The steam bath made her epiglottis swollen which caused the noise when she was breathing. At least that's what the doctor's said.


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## medicstudent101 (Apr 3, 2011)

You gave the answer away already!!

Haha..No worries though. I was going to go with epiglottis anyways. Although if it were my system, we would've just ground pounded her to the Children's Hospital. Our protocols are quite liberal, just goes to show the variance in area to area cases. Seems like you did the majority of what you could do in respects towards your protocols. The only thing I would of possibly questioned would be the transport decision. Though, I was not on the run nor am I familiar with your protocols. Good job on the run though!


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## orange20medic (Apr 3, 2011)

Sorry for giving the answer away 

To be fair to the transport decision, the lead medic on the call is known to not be a very good medic. He is scared to death of peds and literally said nothing on the call. I would have been nervous taking the pt by ground because of the situation. We were all afraid she was going to crash and wouldn't know what was wrong or how to treat her. Being a basic (and the only female) on the call, they had me sit on the bench seat and hold her hand to comfort her. She had 3 scary guys hovering over her, making her nervous, and possibly made it harder for her to breath. She wouldn't let us bag her and tried to rip the IV out. There was good reason behind flying her, and maybe you would just have had to be there to see the situation.


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## Veneficus (Apr 3, 2011)

Vaccinations are such a wonderful thing.


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## orange20medic (Apr 3, 2011)

Veneficus said:


> Vaccinations are such a wonderful thing.



Is there a vaccination against Epiglottitis? 

And yes, I totally agree with you. I don't understand when people are so against vaccinations.


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## Veneficus (Apr 3, 2011)

sara22emt said:


> Is there a vaccination against Epiglottitis?
> 
> And yes, I totally agree with you. I don't understand when people are so against vaccinations.



against epiglottitis specifically, no.

Against the primary bacteria that causes it, yes.


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## medicstudent101 (Apr 3, 2011)

Veneficus said:


> Vaccinations are such a wonderful thing.



Yes, yes they are B)


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## medicstudent101 (Apr 3, 2011)

Correct me if I'm wrong, but children usually get HIB shots as apart of their vaccination regimen. It decreases the likelihood of their chances of developing epiglottis.


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## orange20medic (Apr 3, 2011)

Veneficus said:


> against epiglottitis specifically, no.
> 
> Against the primary bacteria that causes it, yes.



Oh okay. 

Another question- is there any specific treatment a Paramedic can initiate that would help a pt suffering from difficulty breathing from epiglottitis?


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## medicstudent101 (Apr 3, 2011)

sara22emt said:


> Oh okay.
> 
> Another question- is there any specific treatment a Paramedic can initiate that would help a pt suffering from difficulty breathing from epiglottitis?



Epiglottis is a very serious condition. Even more so if you have paramedics who can't readily identify what exactly's going on. To make things worse, the Tx for epiglottis could potentially exacerbate it as it pertains to the pre-hospital setting. Worse comes to worse, you intubate the pt. The issue with that is if you can't get the tube in the first time, good luck trying to maneuver it again. The tube as well as the laryngoscope will just irritate the epiglotis and increase the inflammation. In other words, what was already partially(if not almost completely) obstructing the airway has gotten bigger and much more difficult to manage. Along with that, your obvious IV fluids. 

In the hospital, they'll do the same(if it's that servere) with the addition of corticosteroids that will help with the inflammation as well as IV antibiotics that will help with the infection which may be what's causing the epiglottis.


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## Veneficus (Apr 3, 2011)

sara22emt said:


> Oh okay.
> 
> Another question- is there any specific treatment a Paramedic can initiate that would help a pt suffering from difficulty breathing from epiglottitis?



The important thing is to maintain the airway.

Steroids are useful for not only the inflammation of the epiglottis, but they also help reduce the the potential meningitis sequele as well.


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## Veneficus (Apr 3, 2011)

medicstudent101 said:


> Correct me if I'm wrong, but children usually get HIB shots as apart of their vaccination regimen. It *significantly* decreases the likelihood of their chances of developing epiglottis.



It is not mandated, but it is highly recommended. Some places make you pay for it. 

But since it helps prevent a majority of epiglottitis and one of the causal organisms of meningitis, it makes absolutely no sense to me not to get it. 

Of course people refuse vaccination for Hep B and HPV, which can actually prevent their respective cancers. 

People are strange.


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