Location: Emergency room
Presenting complaint: A 7-month-old boy presents with severe breathlessness of sudden onset
Pulse: 100/min, B.P: 80/55 mm Hg, Temp: 98.70F, R.R: 40/min, Weight: 6.8 kg (15lbs), Height: 53 cm
A 7-month-old boy is brought to the ER with severe cough, stridor, and breathlessness. His 6-year-old brother went to school leaving peanuts near him. Mom found the child in respiratory distress and rushed him to the hospital. There is no family history of asthma. The infant was healthy prior to this incident. Developmental milestones are being achieved at the appropriate ages. He has no allergies. Vaccinations are up-to-date. FH: Father is 32 and healthy; mother is 28 and has DM. He has one elder brother who is healthy. ROS are unremarkable.
How to approach this case:
This child presents with acute dyspnea due to upper airway obstruction. Stridor is one of the important clinical signs of upper airway obstruction. There are a number of causes of upper airway obstruction in the pediatric population. Etiologies vary according to the age of the patient. Careful history, and examination as well as lateral and PA chest X-rays should be done in all such patients.
Results of PE
General examination: The baby is crying, and in obvious respiratory distress.
Chest/lungs: The child is tachypneic with nasal flaring, suprasternal, and intercostal retraction. Inspiratory stridor is noted. Air entry is reduced, and percussion note is resonant bilaterally.
CVS: Normal S1 and S2. No murmurs, rubs, or gallops. Pulses are normal. No jugular venous distension. Blood pressure is equal in both arms.
Oxygen inhalation, stat
IV access, stat
Pulse oximetry, stat and continuous
Cardiac monitoring, stat
CXR-PA/lateral views, portable, stat
X-ray neck lateral views, portable, stat
CBC with differential, stat
Results of Labs:
CXR PA and lateral views: No abnormality found.
Pulse oxymetry: oxygen saturation is 91 percent on room air, and 97% on 2-lit oxygen.
Cardiac monitoring: no abnormality of rate or rhythm.
This child has sudden and dramatic onset of symptoms. He had peanuts in the vicinity before he developed symptoms. Based on these findings, symptoms are most likely due to aspiration of a foreign body. The next step in this case would be bronchoscopy, which will confirm the diagnosis and aid in the removal of aspirated foreign body. Before bronchoscopy, IV steroids and IV antibiotics may be used to help reduce the chances of edema and infection. Other important causes of upper airway obstruction include croup, laryngitis, epiglottitis, retropharyngeal abscess, angioedema, peritonsillar abscess, and laryngeal papilloma. Croup is common in children aged 6 months to three years and it develops insidiously as an upper respiratory tract infection. Patients with croup have a characteristic barking cough. Laryngitis occurs in children aged greater than five, the voice is hoarse, and there is no stridor. Epiglottitis is more frequent in children aged 2-6 years. There is a short prodrome, drooling is noted, and the patient feels better when leaning forward. Patients with retropharyngeal abscess are usually younger than 6 years, and they do not have stridor. The voice is muffled and they are found to be drooling. Angioedema can occur at any age, onset is sudden, and clinical features of stridor, retractions of intercostal muscles, and facial edema are found. Peritonsillar abscess occurs in children greater than 10 years of age, onset is gradual but with sudden worsening, and there is no stridor. Laryngeal papilloma is encountered in patients of ages 3 months to 3 years, onset is chronic and voice is hoarse.
The majority of foreign bodies are not visible by plain films. So, a normal radiograph can never rule out aspirated foreign body in a highly suspicious patient like this.
IV methylprednisolone, one dose
IV cefazolin, one dose
Bronchoscopy, stat (It will ask you surgery consult. Reason: Confirmation and removal of aspirated foreign body by bronchoscopy)
Foreign body aspiration