#croup

Of course, when the beans are this mad/anxious and working this hard to breathe, there's no way you can get them to take any oral medications. My nursing colleague and I attempted to decrease his stridor in whatever ways did not require him to swallow--I put him face-down in my arms with his chubby little cheek smooshed against the lateral condyle of my elbow, rocking him and patting his little diapered butt. Eventually that calmed him enough to stop crying, and his stridor improved enough for my nursing colleague to get him to take a few puffs from an epinephrine MDI. His stridor got a bit better still and now could be heard faintly as the chunker dropped off to sleep, probably exhausted from crying and breathing so hard.

Unfortunately... we already knew this little guy would start screaming again if we moved him, and he was now too sleepy to actually swallow any oral meds... so we weighed the options with his caregiver and opted to give his steroid medication as an intramuscular injection, since then we could at least ensure he received the whole dose. Predictably, the little guy was NOT happy to be poked while he had finally nodded off, so I resumed rocking him and patting his little butt.

Maybe twenty minutes later, after all his medications were in, I arranged the little bean in his mother's arms in the same prone position as he had been in mine; he protested stridorously for a few minutes before settling back to sleep. (During this transfer over to mom, we all became acutely aware of the string of drool from the beany bean's face down my elbow and reaching literally all the way to the floor... I was honestly kind of impressed.)

Thankfully, the steroids kicked in as expected and when I checked back in the next few times our little chonk was fast asleep in his carseat with no stridor and no work of breathing. Eventually he and his brother were discharged with an anticipatory dose of oral steroids in case his brother developed similar symptoms, and instructions to come back if those symptoms returned or worsened. The babies' poor caregiver looked so exhausted (but relieved).

Topics Covered: - Epiglottitis

- Croup

- Bronchiolitis

- Foreign Body Aspiration

- Vascular Ring

- Pneumonia

Pre-reading Quiz:

1. Stridor is heard during ________ (inspiration/expiration), whereas wheezing is heard during ________ (inspiration/expiration).

2. Treatment of ____________ is nebulized racemic epinephrine + dexamethasone.

3. CXR for __________ will show unilateral hyperinflation +/- tracheal deviation to the opposite side.

Epiglottitis

What: bacterial infection of epiglottis w/ Hib, GAS, S. pneumo, S. Aureus

Why: hematogenous spread, unvaccinated (Hib)

Treatment: Ceftriaxone + Vancomycin, Endotracheal intubation

Buzzwords 

tripod positioning

drooling, distress, dysphagia

Croup (Laryngotracheal bronchitis)

What: Parainfluenza virus >> RSV

Why: Hemagluttinin permits viral entry, Neuramidinase permits spread.

Sx: Prodromal phase w/ rhinitis/congestion, then cough in late evening

Treatment: 

Nebulized Racemic epinephrine

Dexamethasone

Humidified air

Heliox decreases work of breathing

Buzzwords:

Barky cough worse at night

Inspiratory stridor

Bronchiolitis

What: RSV in patient less than 2 years old

Why: viral infection and inflammation of bronchioles

Sx: Prodrome phase w/ rhinitis/congestion, then cough/wheezing/crackles and respiratory distress

Treatment:

Nasal suctioning

Supplemental oxygen

HFNC, CPAP

Albuterol/epinephrine, Corticosteroids if severe

Palivizumab monthly during RSV season for first year of life if (premature <29 weeks, heart/lung disease, immunocompromised)

Buzzwords

URTI > Respiratory distress

Foreign Body aspiration

What: acute onset SOB due to foreign body in airway

Treatment:

Rigid bronchoscopy

Buzzwords

Sudden onset SOB

Hyperinflation + mediastinal shift

Decreased breath sounds

Vascular Ring

What: congenital aberrant branch of aorta encircling esophagus/trachea

Sx: Inspiratory and Expiratory stridor w/ history of noisy breathing since birth OR dysphagia to solids

Dx: CTA

Buzzwords

Biphasic stridor

Worsens with crying/feeding

Improves w/ neck extension

Pre-reading Quiz Answers:

1. Stridor is heard during ________ (inspiration/expiration), whereas wheezing is heard during ________ (inspiration/expiration).

2. Treatment of _Croup_ is nebulized racemic epinephrine + dexamethasone.

Like an illness, that you just do not get if you're under 12... And yet, here I am.

Pediatrics (neonates to school age; adolescence is another topic) is probably my least favorite specialty to deal with and they are one of the hardest to help at times with all the elements that go with the patient. Whether it is dealing with the sick child or the distraught parents, we must sift through the physical findings and the information from the parents to understand what is going on. This gets especially sticky when it comes to some upper airway complications in the younger group.

Two very common upper airway problems in the younger populations include Croup and Epiglottitis. Both can be dangerous, but require different management when treatment is concerned. This article will give you a brief overview of the pathophysiology, signs and symptoms, treatments, and key points to remember.

Croup

Pathophysiology: Commonly a viral infection (RSV, adenovirus, influenza A and B, etc.) of the upper respiratory system for ages 6 to 36 months. Major inflammation has occurred in the larynx, trachea, bronchi, bronchioles, and lung parenchyma; causing obstruction of the airway. As the swelling progresses supraglottic the patients with begin show signs of respiratory distress. Further along, the patient’s lower airway may begin to begin having atelectasis, due to the lack of air keeping the alveoli open.

Croup is a slow progression of inflammation. Noticing early that the patient has upper respiratory issue is key in the management. Due to the smaller airway of children, we must not hesitate to seat

Signs and Symptoms: The most common sign of croup will be the seal like bark with inspiratory stridor. With this means that the patient is in respiratory distress and quickly heading to failure. If you hear the seal like bark, check the lower lung fields for crackles, because possible atelectasis may have begun.

Commonly more serious during night, awakening them from sleep. Other signs to know include:

Tachypnea

Retractions

Cyanosis

Shallow respirations

Fever

Treatment: Emergency treatment for croup is a humidified air and a dose of corticosteroids. If in further destress, racemic epinephrine will assist with edema. ETCO2 and O2 readings will help determine if there is retention of gasses, which may lead to acidosis. ABGs will be needed to confirm this as well.

Usually, patients will be able to return home to be monitored. Family should watch for difficulty breath and be using humified air. Antipyretics will assist in keeping fevers down as well.

Epiglottitis

Pathophysiology: Influenza type B, streptococcus pneumoniae or aureus may cause epiglottitis. The epiglottis is a small flap above the glottic opening, which is used to prevent foreign objects entering the trachea. When the epiglottis is infected, with will swell, narrowing the airway for the patient. Increased work of breathing may occur and soon my might have a patient in respiratory failure.

Epiglottitis is a more acute problem, with sudden onset and quick changes to mentation form the restriction of airflow.

Signs and symptoms: As the epiglottis swells, the child may begin to develop stridor. When stridor occurs, we must ask the question is this an object or is this medical. Other signs that might point you towards epiglottitis will be:

Sore throat

fever

Odynophagia

Drooling

Irritability

Cyanosis

Tripoding or nasal flaring

Treatment: The most important thing with these patients is to ensure they have an airway. Do not try and examine the patient, especially if you are a paramedic on scene (Load and go). When gathering a medical history, it is especially important to ask for vaccination in the pediatric population. Today, Influenza vaccinations are given to children, but we do have a set population now that do not vaccinate their children. X-rays of neck will be done and a visual examination may be performed. Keep the patient calm at this time, further agitation may cause the airway to swell more.

Patient will commonly receive an antibiotic, such as ceftriaxone, to help with the bacteria. ET tubes may be places in severe cases and usually remain for 24 to 48 hours. Trachostomes may be required, if a ET tube cannot pass the glottic opening.

Key Points

 Both Croup and Epiglottitis can be dangerous to pediatric patients. If you have a child that has stridor and any signs of distress, they will need immediate attention.

Out of hospital, assume epiglottitis and rule it out when you can. This load and go for you

Croup X rays may show steeple sign, but epiglottitis won’t

Written by: MEDDAILY