# 5 year old difficulty breathing



## alcoholwipe (Aug 21, 2021)

You are dispatched at 2am to a gated community residence. For a 5 year old difficulty breathing.

Fire is dispatched and gets there 15 minutes before you.
When you arrive on scene fire states the patient "looks crappy" and is "unhappy"

As you enter scene mother says child felt unwell today and "was hot" was sleeping in bed with her but did not have difficulty breathing until now. Patient is drooling and has some accessory muscle usage, clothes have been removed by mother prior to fire arrival. Pulse ox is 100% as fire have them on 15ltr, BP 92/60, HR 130, temp 102.6 Lungs clear and equal rate of 34 slightly shallow. Patient gaze tracks normally, responding appropriately. Good color albeit a bit red/flushed.

No past medical history, mother gave Tylenol on instruction from nurseline 4 hours ago. No issues.
Visualization of the mouth looks normal apart from some excessive drooling.


Children's specialty hospital 40 minutes west. Normal ER with OR in hospital 10 minutes east.


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## NomadicMedic (Aug 21, 2021)

*Epiglottitis. *
5ml nebulaized epi 1:1 and an easy transport to the ED 10 minutes away.


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## GMCmedic (Aug 21, 2021)

Upper airway sounds? Stridor? Is child talking.


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## DesertMedic66 (Aug 21, 2021)

NomadicMedic said:


> *Epiglottitis. *
> 5ml nebulaized epi 1:1 and an easy transport to the ED 10 minutes away.


This.

Fits the clinical criteria for it. Keep little dude calm and do a gentle transport to your closest.


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## GMCmedic (Aug 21, 2021)

Geeze guys. I was trying to drag it out a little bit...lol


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## DesertMedic66 (Aug 21, 2021)

GMCmedic said:


> Geeze guys. I was trying to drag it out a little bit...lol


Kinda hard to drag it out when it seems to be a very classic presentation of a topic that is covered in all levels of prehospital care.


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## alcoholwipe (Aug 21, 2021)

NomadicMedic said:


> *Epiglottitis. *
> 5ml nebulaized epi 1:1 and an easy transport to the ED 10 minutes away.


Child struggles when giving neb.
Difficulty breathing increases, stridor now heard on expiration.


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## E tank (Aug 21, 2021)

prep neck...prepare needle cric...


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## alcoholwipe (Aug 21, 2021)

E tank said:


> prep neck...prepare needle cric...


You have never done a needle cric on a child this age. 
Do you perform the cric in the field?
What are your sedation decision ?


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## DesertMedic66 (Aug 21, 2021)

If the cric needs to be done and it is in your protocols to do so, then yes it should be done in the field.


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## alcoholwipe (Aug 21, 2021)

DesertMedic66 said:


> If the cric needs to be done and it is in your protocols to do so, then yes it should be done in the field.


I personally feel that is a bit fast on this patient. What is your concerns for immediate cric.


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## E tank (Aug 21, 2021)

alcoholwipe said:


> What are your sedation decision ?


CO2 and hypoxemia


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## DesertMedic66 (Aug 21, 2021)

alcoholwipe said:


> I personally feel that is a bit fast on this patient. What is your concerns for immediate cric.


I only said if it does need to be done then it should absolutely be done.

Based on the statement “difficulty breathing increases and strider is now heard” doesn’t mean it needs to be done right this second but it is certainly heading that way. So it might be a good idea to get out your supplies.

One may also be able to make an argument for a very mild dose of Versed IN which may allow the patient to tolerate the nebulized epi/racemic epi.

Trying to start a line on this patient is likely to only increase the rate at which the airway is closed.


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## alcoholwipe (Aug 21, 2021)

DesertMedic66 said:


> I only said if it does need to be done then it should absolutely be done.
> 
> Based on the statement “difficulty breathing increases and strider is now heard” doesn’t mean it needs to be done right this second but it is certainly heading that way. So it might be a good idea to get out your supplies.
> 
> ...


Is racemic epi still in your protocols for epiglottis? The research shows neutral benefit and even negative due to disturbing the airway.


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## DesertMedic66 (Aug 21, 2021)

alcoholwipe said:


> Is racemic epi still in your protocols for epiglottis? The research shows neutral benefit and even negative due to disturbing the airway.


Our pediatric ED doc, pediatric intensivist, and medical directors left it in our guidelines for our newest revisions.


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## alcoholwipe (Aug 21, 2021)

DesertMedic66 said:


> Our pediatric ED doc, pediatric intensivist, and medical directors left it in our guidelines for our newest revisions.


Ah it was removed from our guidelines for Epiglottis prehospotal due to neutral and negative research


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## DesertMedic66 (Aug 21, 2021)

alcoholwipe said:


> Ah it was removed from our guidelines for Epiglottis prehospotal due to neutral and negative research


Ours isn’t “if epiglottis then give”. It’s if you have stridor then it’s something you can consider.


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## alcoholwipe (Aug 21, 2021)

DesertMedic66 said:


> Ours isn’t “if epiglottis then give”. It’s if you have stridor then it’s something you can consider.


Ours has epiglottis as a contraindication


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## alcoholwipe (Aug 22, 2021)

E tank said:


> CO2 and hypoxemia


We have awake cric with Ketamine for adults but I've never done it on a ped.


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## Arctan (Oct 12, 2021)

Could you give the child Albuterol?


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## DesertMedic66 (Oct 12, 2021)

Arctan said:


> Could you give the child Albuterol?


Sure you could but it’s not going to help nor is it really indicated in this patient.


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## Arctan (Oct 12, 2021)

Okay, thanks.


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## Arctan (Oct 12, 2021)

What about a Nasal Cannula? Wouldn't that help if his SpO2 is low?


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## DesertMedic66 (Oct 12, 2021)

Arctan said:


> What about a Nasal Cannula? Wouldn't that help if his SpO2 is low?


If his SpO2 was low then sure it would probably help. However with everything going on with this kid, blow by oxygen is probably going to much better tolerated as nothing will be touching their face.


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## Arctan (Oct 13, 2021)

Okay, Thanks!


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## Chris EMT J (Apr 10, 2022)

alcoholwipe said:


> You are dispatched at 2am to a gated community residence. For a 5 year old difficulty breathing.
> 
> Fire is dispatched and gets there 15 minutes before you.
> When you arrive on scene fire states the patient "looks crappy" and is "unhappy"
> ...


Ok late to this scenerio but also new to the forum so don't hold it against me. ABCs? SAMPLE? Place a IV start a litter of fluids for soft BP and fever= possible dehydration. Spo2 was good but there was some accessory breathing so run a nebulizer. Heart rate elevation is common with infections and dehydration is common with fever which soft or low BPs are common with dehydration so In conclusion IV fluids and a neb transport to closest ED. If airway is not being protected BVM and get paramedic to consider a RSI.


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## silver (Apr 10, 2022)

ChrisEMTA said:


> Ok late to this scenerio but also new to the forum so don't hold it against me. ABCs? SAMPLE? Place a IV start a litter of fluids for soft BP and fever= possible dehydration. Spo2 was good but there was some accessory breathing so run a nebulizer. Heart rate elevation is common with infections and dehydration is common with fever which soft or low BPs are common with dehydration so In conclusion IV fluids and a neb transport to closest ED. If airway is not being protected BVM and get paramedic to consider a RSI.


The patient is 5y/o. That BP is normal, and HR is maybe just a bit high. Would you give 1L of fluid?

If you think epiglottitis as others had mentioned, would you wait around to intercept with a paramedic to RSI?




Not so easy


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## johnrsemt (Apr 14, 2022)

HR is normal for a child with a temp that high;  remember the average HR goes up 10-15 for every degree of temperature:  (Took me a couple of years of being beat by my medics to remember that).
BP is good.

If you have a child that doesn't do nebulizer's well, ask them if their parents have taught them to smoke yet?  when they respond no (and hopefully that is the answer), give them the handheld nebulizer and let them smoke it.  It has worked great for me, except when it is time to take it away..


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## Chris EMT J (May 26, 2022)

silver said:


> The patient is 5y/o. That BP is normal, and HR is maybe just a bit high. Would you give 1L of fluid?
> 
> If you think epiglottitis as others had mentioned, would you wait around to intercept with a paramedic to RSI?
> 
> ...


I misread. I thought it said 15 at the time.


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## Tigger (May 27, 2022)

ChrisEMTA said:


> Ok late to this scenerio but also new to the forum so don't hold it against me. ABCs? SAMPLE? Place a IV start a litter of fluids for soft BP and fever= possible dehydration. Spo2 was good but there was some accessory breathing so run a nebulizer. Heart rate elevation is common with infections and dehydration is common with fever which soft or low BPs are common with dehydration so In conclusion IV fluids and a neb transport to closest ED. If airway is not being protected BVM and get paramedic to consider a RSI.


What indication is there for albuterol here?

Accessory breathing is not indication for albuterol. 

Maybe an IV is indicated. BVMs don’t protect airways. RSI?!


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## Chris EMT J (May 27, 2022)

Tigger said:


> What indication is there for albuterol here?
> 
> Accessory breathing is not indication for albuterol.
> 
> Maybe an IV is indicated. BVMs don’t protect airways. RSI?!


I re read the post because I have been mixing up a few things on this one. If no wheezing then no albeterol. Not sure why I said RSI. But I would expect to be suctions the airway if the drool starts to obstruct.


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## MrBrown (Jun 12, 2022)

I am bloody terrible at kids.  I had almost zero clinical exposure to them.  I wholeheartedly agree epiglottis though.

So, imagining the child is now in some form of extremis with a poor airway.  The choices are (a) stay, (b) go to 10 minutes away big persons hospital, or (c) go 40 minutes to little person specialist hospital.  I agree little people generally need a little people specialist.  However, I would take the child to the 10 minutes away hospital with *very early *notification, like before leaving the house early.  If it is 2 am this hospital could well have an ED staffed by a Registrar overnight with no on-site consultant, surgeon or anaesthetist.  I make the point because this hospital has an operating theatre.  Operating theatres come with anaesthetists.  So, that is favourable.  But, they are going to need to come in.  Even if by good luck (more than anything I suspect) there is an on-site anaesthestic doctor, it is also likely to be a Registrar.  I doubt they will have any experience in emergency airway management in small patients.  They might ... but yeah, guessing not.  So, pass hospital message very early so they can call in people.

Now, in saying this, if moving towards the small people hospital was moving *toward *backup that could come out such as paediatric retrieval team or ambulance doctor-based response then perhaps it makes more sense to go that way.  Dare I say, and perhaps of a Strawbridge argument, is an air-based response coming *toward *us as we move toward them? Assuming an appropriate clinical crew (really thinking a doctor) is with the machine *and *they can fly at night (not all can), and we were travelling along somewhere the Fire Brigade could close the road or something then assuming it takes 5 minutes to get off the ground and maybe 5-10 minutes to fly and land, then that is probably better than going to the close hospital.  I would, however, want to have a short but very focussed discussion with the helicopter crew before deciding to leave the scene and head away from the close hospital.


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