There is nothing scarier than a sick kid. I am becoming more and more obsessed with educating myself on pediatric emergencies. This is because of that fear, and the fact that I find it is one of those areas that I am less versed in. This post is aimed at identifying and treating the child who presents with an upper respiratory infection (URI) like croup or epiglottitis. These kids sound sick, look sick, and may get even sicker.
As always, aggressive airway management may be indicated if the child appears to have impending respiratory failure. Signs of this include severe hypoxia, bradycardia, and decreasing respiratory effort.
If the patient doesn’t present with imminent signs like those mentioned above, it is pertinent to obtain a good medical history.
History:
Has the child ever had a URI in the past?
- If so, did he/she present like this?
Was the onset acute or gradual?
- Epiglottits generally presents with an acute onset.
Has the child been sick, and is he up to date with vaccinations?
- Most cases of epiglottitis are caused by haemophilus influenza or H.flu
Has the child ever been intubated?
- This helps identify whether you will need to be aggressive, and a recent intubation could be the cause of hoarseness.
Epiglittits is actually inflammation of the epiglottis–you know, that flap that covers the trachea during swallowing? If this becomes inflamed, it swells, and that swelling could cause a partial or even a complete occlusion of the trachea, thus compromising ventilation.
- Usually febrile, without cough
- Patient may be in tripod position
- Drooling present
Treatment
- Immediate intubation may be indicated (may be very difficult!)
- Epinephrine may be administered in extremis
Croup or laryngotracheobronchitis is also an upper respiratory infection that may be mild, moderate, or severe. It tends to be worse at night, and is most commonly identified by the classic “seal-bark cough”.
- Inspiratory stridor & “barking cough”
- Often preceded by flu
- More likely if they have had croup before
Treatment
- Oxygen therapy
- Nebulized Saline
- If severely hypoxic, racemic epinephrine may be indicated.
- It is often taught to take these children outside, into colder air
So who is in extremis?
- The severely hypoxic child: Cyanosis, bradycardia
- Intercostal retractions with decreasing stridor is an ominous sign of impending respiratory failure
- Decreasing mental status means decreasing respiratory drive. TREAT AGGRESSIVELY
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Check out Justin, The Happy Medic, Schorr’s last run-in with croup in THIS POST.
Great reminders! I keep forgetting to record my daughter’s constant battles with croup, which does come on suddenly without much of a runny nose preceding it. They key, as you mention, is early recognition and baseline mental status/fatigue levels. When my 4 year old gets her cough, she often is so tired and unable to breathe normally she gets tired, but not so much it is a danger.
I was not comfortable with this condition until it struck my family.
Justin
Hi Mark Albert, Pharmacist and consultant for NYC REMSCO, i think we contraindicate intubation for croup, im going to double check it with our protocols. question- to you think for stidor any merits to have in the units racemic epi?
My last run in with croup http://paramedicine101.com/2010/10/22/little-adults/
Justin,
I think the more you experience any condition, the more comfortable you are with it. The first time I witnessed a child with croup, I was nearly ready to prepare my intubation equipment. My partner gave some blow-by nebulized saline, and I just watched the magic.
Mark Albert,
We make our own version of Racemic Epi by nebulizing 3mg, which seems like a lot at first, but it is only for severe cases. If you are confident enough in your medics recognition of stridor, then yes I would say that there is merit. I would stress that this is a worst case scenario treatment though, and the adverse effects should be taught thoroughly. I wouldn’t “contraindicate” intubation for any diagnosis, since there are different severities. What does that leave as an advanced airway option? Crichothyrotomy? As with anything, adequate training will lead to the best outcomes. Generally the croup patients can be managed without intubation, but imagine the patient that becomes unresponsive, bradycardic and bradypneic. Providing artificial ventilations may be difficult with these patients. I haven’t done enough research on the topic though, to offer excellent advice–that may be in order.
Justin, I added a link to your post at the bottom. A great case for all of us to learn from.
Adam,
Probably worth mentioning that cases of epiglottitis in children is becoming very infrequent and if you are presented with a case in which your not sure, it is more than likely going to be croup. As you stated, the Haemophilus influenzae type b bacteria was the main culprit for acute episodes of epiglottitis but now is vaccinated against in early childhood. This has led to the sharp decline in the number of cases although other organsims can potentially cause inflammation of the epiglotitis. So checking vaccination status is very important especially when treating an underserved population or recent immigrants that might not have the same vaccination schedules.