7 yo SOB

[Imacho]

Sounds like croup. Racemic Epi.

 

[Angel]

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

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.

I had this convo with my preceptor on a diff call, I wouldn't call it SVT he has no hx of heart problems and HR and everything was normal before this incident. but it IS way too high, \

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?

no to all 3

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

IT DID TO ME, I completely wrote off the "squeal" because it didn't sound like croup to me and the wheezes threw me off. "wheezes get albuterol" I thought it was a really bad asthma attach in which case mag sulfate would be indicated (we don't have it though)

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

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]

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]

thanks, kids always keep us on our toes

 

[Carlos Danger]

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]

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

 

[mycrofft]

Hey! Hey!

Sounds like croup. Racemic Epi.

IMACHO wins the chicken dinner!!

 

[Handsome Robb]

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]

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

 

[NomadicMedic]

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]

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]

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]

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

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

 

[Sublime]

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

 

[Milla3P]

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]

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]

(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]

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

 

[bmedic1681]

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

 

[bmedic1681]

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