Pediatric Scenario

[WTEngel]

USAL asked me to come up with a good general peds scenario for you guys. So here it is...


18 month old, CC of fever and respiratory distress x 12 hours. Call is at 0200 on a night in November.

On arrival you find a 18 month old, average weight, male patient with HR 165, respirations of 55 per minute, SPO2 93%, cap refill exactly 2 seconds, mid axillary temp of 100.1, crying and fussing. The patient's color is average, not great, not terrible, with the general "sickly" appearance."

You identify audible nasal secretions, with some inspiratory "caving" of the chest, lung sounds are generally clear in all fields, although adequate auscultation is not possible while the patient is crying.

Please identify most appropriate initial treatment based on a logical differential diagnosis, and follow up care. Bonus points for anyone who can identify what the hospital's most likely plan of treatment would be based on the patient's probable diagnosis.

 

[fast65]

Right off the bat I was considering croup/epiglottitis, any drooling? Stridor? Cough?

I'm going to start off with some blow-by O2 while mom holds them. Hopefully that will resolve the respiratory distress. I really don't like that respiratory rate or the sternal retractions, but we'll see how the blow-by helps.

Has the child been eating/drinking normal amounts? Skin turgor? Any change in urination/bowel movements?

I'll forego the IV right now and we'll get going to the hospital. If it happens to be croup, I imagine the hospital will start a trial of racemic epi, but I'm probably wrong

Sent from my mobile command center

 

[Katy]

Certainly a sick baby, and in need of the hospital assistance. First thing I'm going to do is attempt to relieve respiratory distress and raise oxygen saturation levels, by giving the patient oxygen. This is also in my hope going to relieve the baby of some fussing and crysing, so I could better auscultate the lungs. A further health history needs to be discussed on the way, questions like,
"How long has the baby had this fever ?"
"How is the baby functioning as far as releasing wastes from the body ?"
"How is his apetite ?"
"Any other complaints such as coughing ?"
"Have you been ensuring the baby gets adequate amounts of fluids ?"
Answers to some of these questions will help me determine if I need to start and IV before I get to the hospital.

 

[WTEngel]

I will wait for a few more replies before I start to go into more detail, however I will say you should be able to rule in a few specific diagnosis based only on the information given.

There are no hidden details, what you see is what you get...

 

[BigBad]

Meningitis, helicopter. Nuff said.

 

[Katy]

Meningitis, helicopter. Nuff said.

Why would you call meningitis before a respiratory condition such as croup ? Croup is my first thought, as the child shows the major signs and lungs appear to be in general pretty clear.

 

[fast65]

I suppose it could be meningitis, the fever, tachypnea, and tachycardia match. However, there was no mention of bulging fontanelles or a rash, which I'm sure would have been noted in the original scenario with our assessment.

If it turns out to be meningitis I don't see "helicopter" being our main treatment. We can establish an IV and run some fluids because he'll probably be dehydrated, then the hospital can do a spinal tap and possibly give some antibiotics and maybe steroids. They'll probably put him on some acetaminophen for the fever.

 

[thegreypilgrim]

18 month old, CC of fever and respiratory distress x 12 hours. Call is at 0200 on a night in November.

Prodrome of URI?

On arrival you find a 18 month old, average weight, male patient with HR 165, respirations of 55 per minute, SPO2 93%, cap refill exactly 2 seconds, mid axillary temp of 100.1, crying and fussing. The patient's color is average, not great, not terrible, with the general "sickly" appearance."

You identify audible nasal secretions, with some inspiratory "caving" of the chest, lung sounds are generally clear in all fields, although adequate auscultation is not possible while the patient is crying.

So, to summarize we have a febrile, tachypneic, toxic appearing child with some increased work of breathing. Has he hit all the appropriate developmental milestones? Is he consolable? Good muscle tone? Percussion sounds? Feeding habits? Urine output? Lacrimation? Vomiting/diarrhea? Any relevant medical history?

For the moment, I'm going to call this a pneumonia - and based on his age and clinical presentation I'm thinking bacterial. Although croup/epiglottitis or RSV are possibilities.

Please identify most appropriate initial treatment based on a logical differential diagnosis, and follow up care. Bonus points for anyone who can identify what the hospital's most likely plan of treatment would be based on the patient's probable diagnosis.

This child appears to be quite ill, but at the moment I'd provide supportive care.

Supplemental O2 via blow-by, ECG, IV access for fluid bolus and watch for changes while we head to the nearest hospital with pediatric services.

In hospital I imagine they'd want a chest radiograph (PA and lateral views) and draw labs for BMP, CBC w/differential, and possibly cultures. Start him on empiric antibiotics (unlikely to identify the offending organism), watch for respiratory deterioration, and continue fluid therapy as needed.

 

[Melclin]

I hate children.

We need more paeds scenarios. I'm so s**t at kids.

Thinking about things that kill kids with resp distress...

1. FBAO (Febrile and enough of a hx to be pretty sure its not this)
2. Epiglottis
3. Croup

Maybe meningitis. Fontanelles?

Is he barking? Is he drooling? Swallowing? Stridor? Hx of croup?

Pending further info...
-If its croup and he gets a little more lethargic, we can neb some adrenaline but I don't think he's there yet.
-If hes got a non-blanching rash we'll get some ceftriaxone into him. Ask mum for the weight. I imagine 600-700mg.
-Some fluid. 200mls over the time we have him.
-O2.


Hospital. Sepsis bloods, cultures, lactate, Chest xray, lumbar puncture, fluid resuscitation and antibiotics. Strep pneumoniae?

 

[WTEngel]

Alright...

So, let me put you guys back on track.

In this scenario, just as in real life, croup would have been obvious. In the absence of stridorous breath sounds, I would not jump to this diagnosis. The copious nasal secretions also make this less than likely.

Epiglottitis would have been obvious also. Had there been mention of heavy drooling, higher temperature, etc. this might have been more likely.

Asthma and bronchiolitis are out. With the absence of lower airway wheezes in the presence of good air movement, asthma/bronchiolitis is pretty easily ruled out. Now, don't mistake the absence of wheezes as an absolute indication that lower airway constriction is not present. Sometimes kids are not able to move enough air to produce wheezes, however with the crying and fussing, this is not the case with this patient. There is also an elevated temperature for this patient combined with thick nasal secretions, making asthma an unlikely contender for the top spot.

Meningitis? Helicopter? I am not even sure where this came from, but it is not reasonably thought out, so I won't address it.

So, a few questions for you guys:

Is this patient febrile? If so, what is your criteria that defines a "febrile" patient.

Is this child's SPO2 critically low? If so, what are your parameters that define critically low SPO2 in peds? Will placing oxygen on this patient help raise the SPO2? What is the likely cause of the lower than normal SPO2?

How sick is this kid? I see some saying they are very sick. Why do you say this? Would you transport this patient with lights and sirens? No lights and sirens?

Does this child need an IV?

So there are a few points to ponder. Let me know. I will say again, all you need to know about this patient is in the original scenario. There is nothing hidden. Don't read too much into it and make it something it is not.

One person has mentioned the most likely diagnosis, however no one has mentioned the most appropriate first treatment yet...

 

[fast65]

If we're gonna start fresh, I'm going to head down the RSV pathway. The patient is really isn't that febrile, from what I remember, fever's in pediatrics down necessarily have to be treated unless over 100.4 F.

RSV tends to be more prevalent in the fall and spring, so that increases my index of suspicion for this child. The symptoms all match RSV, and I suspect it's only in the beginning stages due to the low-grade fever and absence of a cough. An SPO2 of 93% isn't terrible for a kid, but with the tachypnea and retractions, I do believe this kid can benefit from a little oxygen therapy, and if we have it, we'll give him some humidified O2.

As far as a line is concerned, depending on how far out from the hospital I am I'll probably get an IV. If it is RSV then the hospital will establish an IV anyways and run some fluids, so I might as well get that going early on. I'm thinking about 200-240 ml to start.

Once we're at the hospital they take a nasal swab and do a rapid test for RSV, then the line of treatment will be humidified O2 and IV fluids. If his fever spikes then they'll probably give him some antipyretics.

EDIT: Oh, and no I would not transport this patient code 3, he's sick, but not extremely sick.

 

[Katy]

If we're gonna start fresh, I'm going to head down the RSV pathway. The patient is really isn't that febrile, from what I remember, fever's in pediatrics down necessarily have to be treated unless over 100.4 F.

You have to remember though that this temperature was taken at the axillary site, and the temperature is usually considered to be one degree below the actual temperature. So, this babies temperature would actually be considered 101.4, therefore making it a significant enough fever for medication treatment. This is precisely why I don't like using axillary temperatures, because they are always 1 to 2 degrees lower than the actual temperature of the patient.

 

[fast65]

You have to remember though that this temperature was taken at the axillary site, and the temperature is usually considered to be one degree below the actual temperature. So, this babies temperature would actually be considered 101.4, therefore making it a significant enough fever for medication treatment. This is precisely why I don't like using axillary temperatures, because they are always 1 to 2 degrees lower than the actual temperature of the patient.

Oh yes, I forgot about the site it was taken. Thanks for pointing that out, I just woke up and am only on my second cup of coffee

 

[Katy]

Oh yes, I forgot about the site it was taken. Thanks for pointing that out, I just woke up and am only on my second cup of coffee

No issues, thats what were all here for. Even still, the patient's fever isn't too too high, but it will now be considered high enough for treatment.

 

[fast65]

Indeed it is, however, we don't actually care acetaminophen on our rigs here, so I'll let the ED worry about that. It's not too worrisome, but as you pointed out, it is now high enough for treatment.

 

[Katy]

-To address the questions; yes, this patient is febrile. Why and how do I come to this conclusion ? Usually, if the fever is over 100.5 I consider it significant, if it is below that but still elevated, but it is simply a low-grade fever and usually nothing to worry too much about.

-Now, to the next question, no, I would not consider this patient to be critical as far as low SPO2 is concerned. Is his saturation level low ? Yes, but there is a difference between a low saturation level and a critical one. I would closely moniter his SPO2 for any drop, and would apply oxygen.

-I say this child is sick because we have a whole lot of "flags" flying up showing us he is. Fever, elevated respirations, low SPO2, and the general "sick" appearence are all signs that there is a more serious underlining issue. And no, I would not transport with lights and sirens, this patient is sick, but isn't code-level from the given information in the OP.

-Again, given the information in the OP, I would go ahead and start and IV. It is likely that this child is mildly dehydrated and one will be started at the hospital anyways.

Based on all this, I will also go with the assumption of RSV, but, I'm also leaning to the possiblity of early stages of Pneumonia. Chest X-Ray will be able to most likely tell if Pneumonia is the cause.

 

[thegreypilgrim]

Asthma and bronchiolitis are out. With the absence of lower airway wheezes in the presence of good air movement, asthma/bronchiolitis is pretty easily ruled out. Now, don't mistake the absence of wheezes as an absolute indication that lower airway constriction is not present. Sometimes kids are not able to move enough air to produce wheezes, however with the crying and fussing, this is not the case with this patient. There is also an elevated temperature for this patient combined with thick nasal secretions, making asthma an unlikely contender for the top spot.

Like you said, the absence of adventitious breath sounds is not sufficient to rule out anything, especially not in a crying/fussy/squirmy kid. It could sound more or less "normal" but there could still be consolidation or thick secretions obstructing airflow or impeding gas exchange.

Is this patient febrile? If so, what is your criteria that defines a "febrile" patient.

Technically no, since the reading was still <39C but since this was an axillary measurement I wouldn't be surprised if it was falsely low. I'd hold off on antibiotics until I got a rectal temp.

Is this child's SPO2 critically low? If so, what are your parameters that define critically low SPO2 in peds? Will placing oxygen on this patient help raise the SPO2? What is the likely cause of the lower than normal SPO2?

As of the moment, no. As long as it holds at >90% without lethargy or some sort of complicating feature of his history a blow-by mask (if that) should be fine.

How sick is this kid? I see some saying they are very sick. Why do you say this? Would you transport this patient with lights and sirens? No lights and sirens?

With an increased work of breathing and poor general appearance that's two legs of the PAT that are "abnormal". This coupled with the moderate decrease in SPO2% I'd say he's sick, but not critical at this point. No lights and sirens.

Does this child need an IV?

Yes.

 

[exodus]

Has anyone tried to clear out the nose yet and see if constant monitoring of the nares will help the o2 and stress breathing?

I know when I have a really bad cold sometimes it gets mildly difficult to breathe when i have my nasal secretions running down my throat, now add this to a baby crying relentlessly.

A baby crying extremely hard could also mimic labored breathing. Seeing a small baby give a temper tantrum will many times use accessory muscles to try and balance out their o2 levels.

So how do people feel about simply clearing out the airway?

Edit: I don't think rapid cooling is needed, but lets turn off the heat and pull the child out of all the blankets he's in.

 

[Handsome Robb]

If possible I'd want a rectal temp. If it isthe 101.4 like Happy suggested I'd consider some acetaminophen 15 mgs/kg PR (only way we carry it) Other cooling measures like exodus said as well as try and clear his nose as well.

No lights/siren, he needs someone smarter than me when it comes to peds but where I'm at we don't have long transport times. Rural I might consider them intermittently to keep mom happy but I don't think its prudent in this scenario.

His SpO2 isn't awful but you could try some O2 blow-by to help them a little bit and to try and calm the little bugger down to get a better set of lung sounds, maybe consider humidifying it? If his SpO2 started to drop and work of breathing didn't begin to calm down maybe some racemic epi nebbed through a mask, probably gonna be blow-by if he is as agitated as it sounds but I don't know how I feel about the possibility of elevating his HR even farther with the epi.

IV if possible but I don't wanna continue to agitate this kid.

RSV sounds like a good thought so I'll agree with fast on that.

We haven't gotten to peds yet so I may be WAY off on this one.

 

[DESERTDOC]

Lets go with viral.

Clear his nose.

Nebulised saline.

Tylenol, PR.

Check his sugar.

Fluid bolus NS x1.

C-2.