Bongy's quiz No.3 Pediatrics

[Bongy]

Hello my dear collegues!
Aftel short break and few arguments with forum administration,I'm back. As a result of my written conversation with few forum members,I have to clarify some points:
1. All cases that presented by me here happened in real with me or my collegues in Israel EMS(Dan region).
2.Don't let to the name "Quiz" to feel you like in exam - "via mistakes truth will rise" - fell free to post whatever you think.
3.All cases are not trivial... Othervise,life will be boring
So.. Another one..
Time:18:30
Complain:10 month old baby,difficulty to breath
Om arrival:Baby,10 month old,mild cianotic,marked stridor,RR40(using abdominal muscles),Sat O2-95%,HR160
Anamnesis:Fever for last 3 days,average 39.5C(103.1F),family doctor said,that this is a viral and prescribed only paracetamol(supp)....
Difficulty of breath had a sudden onset - infant played on a floor...
So...You hold a baby to check him up... In lungs you can hear clearly stridor, but suddenly you start to hear much loder noises from right lung... HR drops to 90...
So.. Possible diagnosis,DD and treatment tactics.. Estimate transportation time - 45 min.
Good luck!

 

[lfsvr0114]

Sounds possibly like child has aspirated something from the floor and now has pneumonia. With it dropping the heart rate and stridor getting worse, sounds like it moved to impede the airway more and that the child is getting tired of breathing. Support respirations, try not to aggitate the child and haul to the hospital.

 

[Guardian]

Alright Bongy, here goes...


Based on age, high temp, limited hx, I'd guess we're dealing with a bacterial croup (tracheitis) that has progressed into respiratory failure and possibly imminent respiratory arrest. No time to play doctor here, I agree with lfsvr0114's treatment plan with the edition of IV and EKG in route. If available, I'd consider humidified O2 and/or racemic epinephrine and even ETI. With the long 45min transport, I'd call the doctor and get his/her opinion about the epi. And I should add, this is all assuming there are no signs of trauma.


Now bongy, to give you a little help with your english, I recommend from now on that you write difficulty breathing, instead of difficulty to breath.

 

[Bongy]

Now bongy, to give you a little help with your english, I recommend from now on that you write difficulty breathing, instead of difficulty to breath.

Agreed! Thanks...

Now about a case... The problem,presented here has 2(!) different triggers,that lead to respiratoty failure... Pay attention,to SUDDEN onset of respiratory failure...Btw... I brought a child INTUBATED...So...Any ideas?

 

[Guardian]

Sudden onset in pediatrics doesn't mean much considering they compensate right up until the point they fall off the cliff. You're going to have to give me more than that.

I also think you’re being a little vague considering the multitude of conditions that cause respiratory failure. A few include aspiration, pulmonary edema, acute sepsis, meningitis, pneumonia, metabolic disorders, drug toxicity, cardiac problems, structural airway problems, etc, etc, etc. With the information I’ve got so far, it might be any of these. Keep in mind, I don’t have a chest x-ray in the back of my ambulance. Bottom line, I don’t think there is going to be a smoking gun here, only an esoteric diagnosis reached after many sophisticated hospital tests. I gave you my best guess based on a paramedic’s assessment. Although I’m mildly curious as to what the diagnosis was, the treatment remains pretty much the same regardless. For these reasons, I don’t think you’ll get much participation from others with this scenario.

Of course I could be totally wrong…

 

[Bongy]

Sudden onset in pediatrics doesn't mean much considering they compensate right up until the point they fall off the cliff. You're going to have to give me more than that.


Of course I could be totally wrong…

Not at all!! You are generally right...But.. You right about collapse - pediatric pt collapsing very fast because they are NOT very good in compensation... A case is not so obvious and a "smoking gun" is "loud noise" in right lung... Let's think together - I had enough time during transportation. Baby has a underlying disease,that might guide us to laryngitis-tracheitis direction...Well, yes,that what I did - inhalation with epi and o2...To check a throat isn't a good idea,because of laringospasm... On the other hand - baby played on the floor - good environment to aspirate something...
Now,the sudden collapse - best sign for hypoxia is bradicardia,and HR90 in this age is bradicardia endeed... Pt becomes apatic and I lost a breath sounds in right lung... Let's continue from here
P.S. I haven't an x-ray machine in the back of my ambulance ether... We still working on to put one..

 

[Bongy]

So... anybody?? Should I give a diagnosis? Surrendering?

 

[RedZone]

Hmmm... so originally I have a 10 month old who is:

A) Hypoperfusing
B] Viral or bacterial infection (fever) for 3 days.
C) Sudden respiratory distress (eventually with evidence of hypoxia)
D) NOT in respiratory failure

Start with oxygen, IV fluids (20 cc/kg).

But he also has a PARTIAL upper airway obstruction which all of a sudden, after repositioning him, further occludes air passage... but only to one lung. This unilateral obstruction rapidly worsens to complete obstruction.

I'm definitely concerned with croup or epiglottitis. But only one lung leads me to believe foreign body aspiration.

Since you seem to be saying none of those are the case, and there is an underlying disease... I'd have to go with:

Tumor or Abnormal Anatomy (congenital defect). Not something I'd consider prehospitally, but just a guess.

What happens if you put him in the position you found him? Consider steroid maybe?

 

[Bongy]

Since you seem to be saying none of those are the case, and there is an underlying disease... I'd have to go with:

What happens if you put him in the position you found him? Consider steroid maybe?

Well... Actually,I didn't say that it wasn't croup... It was...But what happened next.. RedZone - I truly like your way of thinking! Respect!
So..Diagnosis:
Bacterial croup with mucus hypersecretion... After repositioning of the baby, almost SOLID mucus was aspirated to the lungs and blocked right bronchi. Respiratory distress becomes much more sever,and due to agitation,baby starts to close a larynx completely. In this second I become even more cianotic than a baby - because crushing was very fast... I decide to intubate. After intubation - tube no. 3,I start to ask parents if it is possible that they have any small objects on a floor - they said NO! NO CHANCE... Place for playing was completely clean... I started to think about possible anatomic abnormalities also. When he was on Ambu,I saw asymmetric chest movement,so just to be on the safe side,I "splashed" 2cc of saline with 1/3 cc of Ventoline directly to the tube....and "kind of magic"!!! Normal chest movement restored just after few ambu pressing... On arrival to the hospital - baby sedated,spontaneously breathing,sat 99%,HR 160,no sign for cianosis...
Extubation made 30 hours later in PICU after initial antibiotic treatment...

Any questions?

 

[Guardian]

well, I was half right. that was a good one bongy!