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A breathless child Author Dr. T W Wong Revised by Dr. Chang Wai Yin, James August, 2013

HKCEM College Tutorial. A breathless child Author Dr. T W Wong Revised by Dr. Chang Wai Yin, James August, 2013. Triage. M 2 y/o Fever for 1/7 mother noticed noisy breathing today seen by GP yesterday given tx for URI pulse 140/min RR 42/min Temp 39 °C. Triage Category II.

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A breathless child Author Dr. T W Wong Revised by Dr. Chang Wai Yin, James August, 2013

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  1. HKCEM College Tutorial A breathless child Author Dr. T W Wong Revised by Dr. Chang Wai Yin, James August, 2013

  2. Triage • M 2 y/o • Fever for 1/7 • mother noticed noisy breathing today • seen by GP yesterday given tx for URI • pulse 140/min RR 42/min • Temp 39 °C Triage Category II

  3. What are your ddx at this point? Upper airway obstruction vs Lower airway obstruction

  4. How would you approach this child? The key is to observe at a distance first Assessment Triangle

  5. Check if the kid is in distress Assessment Triangle Appearance: mental status muscle tone Work of breathing RR, retraction, stridor Circulation: color, cap refill, pulse

  6. Check if the kid is in distress Assessment Triangle Appearance: Anxious Sitting on lap of mom Work of breathing RR, retraction, stridor Circulation: color, cap refill, pulse

  7. Check if the kid is in distress Assessment Triangle Appearance: mental status muscle tone Breathing: What will you look for? Circulation: color, cap refill, pulse

  8. Look: nasal flaring retraction suprasternal intercostal subcostal Listen inspiratory stridor expiratory grunt expiratory wheeze Findings yes yes yes yes yes no no Respiratory status

  9. Check if the kid is in distress Assessment Triangle Appearance: mental status muscle tone Work of breathing RR, retraction, stridor Circulation: flushed, cap refill1sec, pulse strong

  10. What is the physiological status of the child? Airway: ? Upper airway obstruction Breathing: respiratory distress Circulation: normal Mental State: alert

  11. What are your ddx at this point? Acute epiglottitisCroupRetropharyneal abscessPeritonsillar abscessBacterial tracheitisAngioedema Do not forget Foreign Body !

  12. What clinical features may differentiate between acute epiglottitis and croup?

  13. Take a history from mother... • Version 1 • Version 2

  14. History by mom--version 1 • High fever start yesterday afternoon • cough occasional • refuse feeding • drooling • this morning prefer holding by mom; won’t lie in his bed DX =>

  15. What is your initial treatment? Describe How? Stabilize ABC

  16. Immediate Treatment • 100% oxygen blow by • do not try to start an IV • ECG monitor PRN • pulse oximeter Do not separate mom from child Bottom Line: do not cause further distress by invasive procedures

  17. What is your next step? Look inside mouth to confirm dx? Send child for X-ray neck? Alert “epiglottitis team”

  18. Look inside mouth? Do not force e.g. with a spatula May cause child to struggle and increase resp distress

  19. X-ray of neck Not necessary in typical case upright portable film may be done in unsure case

  20. What are the signs? Air Trapping Thumb print

  21. Extract from http://www.radiologytutorials.com

  22. Extract from http://www.radiologytutorials.com

  23. note the hypopharyngeal dilatation, obliteration of the vallecula, and thickened aryepiglottic folds—a positive thumb sign.

  24. Who are the members of your epiglottitis team Paed ENT surgeon Anaesthetist Ideally, how should the airway be controlled?

  25. Take the child to OT for airway control Gas induction Start an IV Try oral intubation Gildescope Intubation standby

  26. Go to summary History by mom--version 2 • Mild fever start yesterday afternoon • a lot of cough, hoarse cry, running nose • feeding slightly decreased • no drooling • this morning breathing has become more noisy DX =>

  27. What is your initial treatment Stabilize ABC Describe How?

  28. Immediate Treatment • 100% oxygen • ECG monitor prn • pulse oximeter Any specific treatment for croup?

  29. Adrenaline 1:1000 5ml neb Dexamethasone 0.6 mg IM/IV/PO

  30. What about Xray neck Not necessary in typical case. Neck and CXR for ? FB

  31. What are the signs ? Air trapping Normal epiglottis Church steeple sign

  32. Disposition Emergency/Observation ward? Admit Paed?

  33. Admit if • Significant respiratory distress not responding to initial treatment • Diagnosis not certain • Parents not confident or reliable

  34. Take a history from mother... • Version 1 • Version 2

  35. Summary We have covered: • Evaluation of respiratory distress • Dx and Mx of acute epiglottitis • Dx and Mx of acute croup

  36. The end

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