medic25 Posted November 25, 2014 Share Posted November 25, 2014 Took care of an interesting case this week; thought it might be a good one for the students/new EM PA's to work through a little. CC: fever/shortness of breath HPI: 2yo male, BIB family for fever, cough, and increased work of breathing. Temp of 103 at home today, improved with ibuprofen. Seen by pediatrician earlier in week for fever/URI sx, started on amoxicillin for AOM. Seen at another ED subsequent to that for cough/SOB. Responded to nebs/steroids, treated as bronchiolitis, discharged home. Mom now states breathing is the worst it's been all week. HR- 160, 98/60, RR-30-38, O2 sat 97%, temp 97.3F Exam: Alert, well-developed child, increased WOB. Attempting to speak, but voice is almost inaudible. No obvious stridor. Lungs relatively clear bilaterally (some scattered rhonchi), but abdominal retractions with breathing. Skin pink, no obvious cyanosis/rashes. So what else would you like to know? DDx? Next steps? Fire away! Link to comment Share on other sites More sharing options...
PACdan Posted November 25, 2014 Share Posted November 25, 2014 Haven't gotten to pulm or peds yet, but I'll throw out some questions: Any known sick contacts? (babysitter, playmates, relatives...) Any new plants, pets, or people in the home? Are all his vaccinations up-to-date? How is his feeding/appetite, any changes? Is the ENT exam normal? Can I get a CXR on a 2-year old? Thanks. Link to comment Share on other sites More sharing options...
Deanj59 Posted November 25, 2014 Share Posted November 25, 2014 What's the CENTOR score on the child? Any deviation of the Uvula? Any drooling or barking coughs? Steeple or thumbprint signs if an CXR was done? What did the otoscopic exam reveal? Link to comment Share on other sites More sharing options...
medic25 Posted November 25, 2014 Author Share Posted November 25, 2014 No known sick contacts, but in daily daycare. No new contacts. All vaccinations UTD except for a flu shot. Feeding/appetite have been poor, but is still wetting diapers. CXR can be done, but what are you looking to identify? Uvula midline, no identifiable exudate in throat, left TM is slightly erythematous. Some anterior cervical LNA. You hear a periodic, raspy cough as the orient is sitting in the room. Link to comment Share on other sites More sharing options...
Deanj59 Posted November 25, 2014 Share Posted November 25, 2014 Does the left TM move with insufflation and is a cone of light present? Was a CBC with differentials, ESR, or procalcitonin done? I remember that day care is a predisposing for AOM infection. Hmm, all I can think of at this point is either recurrent AOM or CF. Not sure what state you practice in but all kids in CA at least get screened at birth for that along with the other errors of inborn metabolism. As far as what I would be looking for in the CXR, air bronchograms, lobar consolidations (were the lung fields resonant to percussion?), or any interstitial infiltrates. Link to comment Share on other sites More sharing options...
PACdan Posted November 25, 2014 Share Posted November 25, 2014 With the lymphadenopathy, I'm thinking infectious process. CXR to look for consolidations, infiltrates, expansion, steeple sign for croup, and lateral neck view for epiglottis r/o. Also long shot for partially obstructing foreign body in the airway/bronchi. Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 25, 2014 Moderator Share Posted November 25, 2014 rsv? Link to comment Share on other sites More sharing options...
primadonna22274 Posted November 25, 2014 Share Posted November 25, 2014 Also long shot for partially obstructing foreign body in the airway/bronchi.FB ingestion or aspiration is never a long shot in a kid. Always keep this in mind on your differential. 2 yo put everything in their mouths and are quite mobile. Link to comment Share on other sites More sharing options...
KMD16 Posted November 25, 2014 Share Posted November 25, 2014 ....sounds like a bad case of acute bronchiolitis (usually progresses to respiratory distress) that warrant Inpt mgmt or observation. What was the result of cbc? To look for on CXR are hyperinflation, lobar infiltrate or stele ration which is seen in >20% of cases or radio opaque FB. Another piece of info missing is the child PMHx, of particularly interest birth defects? Was pt premi or full term? Also any recent travel? Link to comment Share on other sites More sharing options...
medic25 Posted November 26, 2014 Author Share Posted November 26, 2014 Insufflation not available in the ED, but cone of light was fairly normal appearing. No pertinent travel history. Child was full term, NSVD, no history of any congenital defects. Didn't immediately get bloodwork. Initial interventions/testing were 0.6mg/kg of dexamethasone PO, nasal DFA swab, and x-rays of the chest and soft tissue neck. Chest x-ray was unremarkable. Neck x-ray is attached (sorry, just have the lateral). Thoughts on the x-ray? After seeing the films, what would you like to do next (e.g. bloodwork, interventions, additional treatments/testing)? Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 26, 2014 Moderator Share Posted November 26, 2014 go clean my drawers out I think I just messed myself then ......... Link to comment Share on other sites More sharing options...
FfIghter23 Posted November 26, 2014 Share Posted November 26, 2014 Thumbprint = epiglottitis. Intubate stat. Once airway secure start abx covering for H. Flu. Link to comment Share on other sites More sharing options...
medic25 Posted November 26, 2014 Author Share Posted November 26, 2014 go clean my drawers out I think I just messed myself then ......... Yup, took care of that immediately :) Link to comment Share on other sites More sharing options...
KMD16 Posted November 26, 2014 Share Posted November 26, 2014 Enlarged epiglottis. Secure the airway STAT! Link to comment Share on other sites More sharing options...
medic25 Posted November 26, 2014 Author Share Posted November 26, 2014 Thumbprint = epiglottitis. Intubate stat. Once airway secure start abx covering for H. Flu. Exactly; classic x-ray findings of acute epiglottitis. Per the textbook, yes this is an immediate intubation. In real life, we had to bring some elements of clinical judgement. We took care of this patient in our free-standing ED. No onsite specialties; i.e., no anesthesia, no ENT, no ICU. This leaves us with two options: 1) Establish vascular access, RSI, intubate, then abx and transfer. 2) 15 minute ground transport to Children's Hospital; transport patient there for intubation and further airway evaluation. For the new EM PA's; what are the pros/cons of either approach? If going with option 2, what do you do with the patient prior to transfer (e.g. IV fluids, antibiotics, additional medications)? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 26, 2014 Moderator Share Posted November 26, 2014 recently saw an adult with epiglotitis and stridor from freebasing cocaine. ended up with nasal intubation done by ent. Link to comment Share on other sites More sharing options...
PACdan Posted November 26, 2014 Share Posted November 26, 2014 Scary. They told us not to poke around with those; call anesthesiology or ENT stat. They said a little agitation can cause near immediate swelling. I guess if you had to intubate right then and there, have a surgical airway prepped and standing by? On such a tiny kid that would suck, but then so does dying. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted November 27, 2014 Share Posted November 27, 2014 What was the patients position of comfort when you walked into room? If he was tripoding and drooling, then its an airway now issue. Call in any help you can get into your ED and get a plastic airway (RSI or cric). If pt is sitting, moving, lays back, good ROM of neck, then transfer to tertiary care. Link to comment Share on other sites More sharing options...
medic25 Posted November 28, 2014 Author Share Posted November 28, 2014 The kiddo looked relatively comfortable, so we set up the airway equipment and consulted the PICU attending by phone. We all agreed it made sense to defer intubation until getting him to a more well-equipped environment. We deferred all IV access/antibiotics and closely monitored him until the arrival of the PICU transport team. He was transferred directly to the OR at the children's hospital with anesthesia and ENT standing by. A mask induction allowed for a much smoother intubation process, after which they could establish IV access and antibiotics without worrying about agitating the patient. Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 28, 2014 Moderator Share Posted November 28, 2014 GREAT JOB!!!!!!!!!!!! only have been involved in one similar in a small outlaying hospital - not my case but the ER attending (FP trained doc) Well he literally almost fell over after getting off the phone with Anesthesia at the tertiary care center after being told to sedate and intubate.... He did neither due to the same above issues - and it was the right call as the kiddo did okay - I for one was glad it was not me managing that patient..... no one was comfortable with that case..... Link to comment Share on other sites More sharing options...
polarbebe Posted December 3, 2014 Share Posted December 3, 2014 Thank you for sharing this interesting case. Link to comment Share on other sites More sharing options...
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