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.
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
- 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
- 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
Check out Justin, The Happy Medic, Schorr’s last run-in with croup in THIS POST.