Pediatric Choking

clibb said:
Does the child have any signs of trauma?
The eyes rolling back indicated a chance for brain injury to me.
With the low SPO2, can also indicate some shock.
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Family reports no trauma. Pt. was being held by family when all of this started.
 
CAOX3 said:
Do they have any other children. First time parents usually report the worst and usually are not a reliable source of information in my expereince.

Kids crying = good sign.

Kids fussing = good sign.

Any inspiratory stridor?

Hows her color? She nice and pink or blue on the tips?

I guess a SZ is a possibility, she been sick, temp anyone else at home sick?

As was stated above by alpha monitor airway and transport.
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Not their first child/no "new parent issues" so to speak. You do hear "coarse" sounds when you listen to tracheal sounds with your stethoscope. Lung sounds are clear everywhere. Nice pink color. No fever.
 
I'll throw in this bit: when you get to the hospital and transfer care, their initial SPO2 reading is 27%. Child is still awake and alert. That's correct...twenty-seven percent. Both you and the tech say "that can't be right" with good harmony.
 
Fox800 said:
I'll throw in this bit: when you get to the hospital and transfer care, their initial SPO2 reading is 27%. Child is still awake and alert. That's correct...twenty-seven percent. Both you and the tech say "that can't be right" with good harmony.
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Okay, so lets recap. We have an 18-m/o female who is becoming increasingly inconsolable and has frequent periods of flaccidly unresponsive. HR is elevated, unknown BP, RR is on target, cap refill was good, O2 sat was either falsely high, or is now falsely low. Skin is warm, pink, and dry. No fever, no med Hx, allergies, medications. No trauma. However, noted "hoarse" sound from trachea.

So only "significant" findings are the flaccid unresponsiveness, the "hoarse" sound, and possibly the SPO2 reading.

The O2 sat is clearly incorrect. The child would be showing signs of hypoxia LONG before then, and be dead to boot. Out of all possible causes of falsely low SPO2, I'd say vasoconstriction. Severe peripheral vasoconstriction pulls blood away from the capillary beds, leading to a low reading.

Possible causes...

- Hypoxia or hypoxemia. This would explain the unresponsiveness and flaccidness. Trachea problem could cause the low O2 sat which causes syncope. This could be due to some "choking" as they stated, a FBAO, etc. However, the kid SHOULD become bradycardic prior to unresponsiveness.

- Atonic seizures. The child would have the period of flaccid unresponsiveness, and the child waking up angry, and this can happen multiple times a day. No other seizure activity fits, as the rest involve non-flaccid muscle activity.

- Vaso-vagal syncope. The vasoconstriction would cause the 27% reading, and the cerebral vasoconstriction causes syncope. This could be caused by a FBAO causing a vagal response by rubbing the carotid sinus, because if it's popcorn and she's 18-m/o, it could be really big compared to her narrow funnel of an airway.

- Some other sort of wacky baroreceptor disorder causing wild changes in BP to cause the constriction/dilation and cause the low SPO2 reading and syncope.

- I would say Hyperventilation causing hypocapnia, causing cerebral vasoconstriction, causing syncope. However, the RR isn't anywhere near fast enough to cause that.

So, to solve this... What are the vitals like prior to, during, and after the syncope episodes? If the kid goes Brady, it's something hypoxia-related. If the kid's RR goes nuts, it's probably Hypocarbia. If it involves the BP, it could be Vagal or baroreceptor-related. If it's none of those, I'll have to say it's an atonic seizure.
 
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Change probe on monitor.

OK, denoument, please.
 
def key to know v/s before, during, and after the syncope. This is prob a situation where I'd be on the phone with a doc and id be seriously considering tubing the child.
 
ah2388 said:
def key to know v/s before, during, and after the syncope. This is prob a situation where I'd be on the phone with a doc and id be seriously considering tubing the child.
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You want to tube this kid?

Care to explain why?

Your kidding right?
 
i guess i may have mistook unresponsiveness to mean apneic...long day...

with that being said, in this specific case it may not be warranted, although i imagine that if the pt was showing signs of poor perfusion, I would like to think id be pretty quick at taking aggressive steps to manage this pt's airway.
 
MonkeySquasher said:
- Atonic seizures. The child would have the period of flaccid unresponsiveness, and the child waking up angry, and this can happen multiple times a day. No other seizure activity fits, as the rest involve non-flaccid muscle activity.

- Vaso-vagal syncope. The vasoconstriction would cause the 27% reading, and the cerebral vasoconstriction causes syncope. This could be caused by a FBAO causing a vagal response by rubbing the carotid sinus, because if it's popcorn and she's 18-m/o, it could be really big compared to her narrow funnel of an airway.
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Ahhh you beat me to it. I was ganna say absence seizure (I though you could get absence seizures with atonicity, but then I guess they'd just be called atonic seizures) or atonic seizure.

I considered vagal stimulation 2ndry to FBAO but you would expect to see some changes in heart rate wouldn't you?

If the SPO2 reading is correct...some kind of atrial septal defect maybe? My understanding of pulse oximeters is that they are accurate only down to a certain saturation, lower than that they tend to be inaccurate. It could be that the kid has a much higher (although still very low) SpO2.
 
Melclin said:
I considered vagal stimulation 2ndry to FBAO but you would expect to see some changes in heart rate wouldn't you?

If the SPO2 reading is correct...some kind of atrial septal defect maybe? My understanding of pulse oximeters is that they are accurate only down to a certain saturation, lower than that they tend to be inaccurate. It could be that the kid has a much higher (although still very low) SpO2.
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I also considered the bradycardia that should happen 2* to the vagal, which is why I wanted the vitals before/during/after. ;D

Yeah, I thought about a heart defect, but figured it HAD to have been picked up by 18mo, wouldn't it? It'd be so extremely rare to have a child go 18-months and then suddenly be this awkwardly symptomatic.

But if the SPO2 was even semi-correct, how is the child so pink and warm and responsive? If that was somehow correct, there's no way the kid's pulse would be that high.
 
MonkeySquasher said:
I also considered the bradycardia that should happen 2* to the vagal, which is why I wanted the vitals before/during/after. ;D

Yeah, I thought about a heart defect, but figured it HAD to have been picked up by 18mo, wouldn't it? It'd be so extremely rare to have a child go 18-months and then suddenly be this awkwardly symptomatic.

But if the SPO2 was even semi-correct, how is the child so pink and warm and responsive? If that was somehow correct, there's no way the kid's pulse would be that high.
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Vagal: Yep, gotcha.

ASD: I think depending on the degree of shunting, ASD can become symptomatic at many different ages. I don't anything more about it than that so my go to spot is eMedicine.

http://emedicine.medscape.com/article/162914-overview

SpO2: Yeah I agree with you about the SpO2, just throwing ideas around. I have a feeling that its supposed to mean more than just a faulty reading seeing as though these scenarios are the zebras and not the horses - the low saturation reading might be a clue...or it might be a confuser to get some over zealous EMT to start bagging a perfectly well pt due to a faulty reading.

Other than that, I'm tagging out of this one for exam week :wacko:
 
I'm rather interested too. I'm not very good at diagnosis yet, but I like reading these and following the thought process of other medically inclined individuals.:)
 
The child was diagnosed with a foreign body aspiration. She was RSI's and taken to the OR for emergency bronchoscopy.
 
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