7 yo SOB

[Angel]

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]

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]

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]

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]

I missed the hr. Transport.

 

[vc85]

BLS here:

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

 

[exodus]

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

 

[Angel]

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]

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

 

[Angel]

like this, I cant get it any bigger though



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

 

[exodus]

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

 

[NJEMT95]

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]

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]

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]

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]

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]

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]

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]

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]

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?