Acute Onset Respiratory distress part 2


• Scene – vitals
• En route – oxygen, albuterol/atrovent neb
• Paramedic requested to give nebulized epi en route to hospital, but was refused (ambulance crew does not carry racemic epi, doctor did not feel comfortable with paramedic mixing his own with 1:1000 and saline)
• Dr. requested code 3, duoneb (albuterol, atrovent) ok en route
• The only thing that made the patient improve was verbal coaching and support from mother – no improvement from nebulizer therapy
• Hospital – racemic epi, X-ray (soft tissue), vitals, EKG, statlab
• Patient became very agitated at the hospital
• Medical team at hospital attempted to start IV to give dexamethasone but may have stopped due to his increased resp effort
• Doctor did order the peds crash cart, and appeared to be planning on intubating the patient
• Mom was able to coach him down and doctor ordered most of the staff out of the room


• Response to treatment –
• En route – patient felt a little bit better with neb tx en route
• Hospital – patient responded very well to racemic epi.; he was smiling and playing just prior to paramedics leaving the ED


• Elliot Williams, Paramedic Woodburn Ambulance
• Matthew Hansen, MD Oregon Health & Science University


• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center

• Croup
• Stridor

Differential Diagnosis

• Croup
• Asthma
• Allergic reaction
• Airway foreign body
• Bacterial tracheitis
• Epiglottitis
• Pneumonia

Patient Workup

• Patient initially presented as very tired, calm; became agitated with medical interventions
• Patient’s mother reports onset 3 days. Normally hot shower helps. Patient got scared, condition worsened and “worried he was going to die;” so mom called 911.

Physical Exam

• When patient gets upset and has a hard time breathing, presentation includes very loud stridor, extreme intercostal retractions, nose in sniffing position, eyes very wide; patient even attempted to crawl up his mom, looking like he was trying to swim above water to get air
• Patient skin is cool to touch, but he appears atraumatic (some dried ice cream on his face)

Editor’s Notes

This was literally the best parenting and care I have ever seen from a parent while working as a medic. Without her keeping her son calm, it’s likely we would have intubated this kid en route to the hospital. – Elliott Williams, Paramedic on scene; Woodburn Ambulance Service

Suggested Approach

• Viral croup is the most common cause of acute airway obstruction in children aged 6 months to 6 years. In a child with classic symptoms, barky cough and inspiratory stridor, the diagnosis of croup is based on the history and physical examination alone. Less than 1% of children with acute onset of inspiratory stridor will have another diagnosis, including epiglottitis, bacterial tracheitis, or a foreign body aspiration.
• Nebulized epinephrine can provide rapid, relief of respiratory distress and is indicated if the patient has stridor while at rest. The onset is within 10 minutes, and the effect lasts 1-2 hours. One oral dose of dexamethasone 0.6mg/kg is the recommended treatment of mild and moderate croup where a barky cough is present and the patient may have stridor with agitation. The effect of the dexamethasone treatment will last several days usually through the worse part of the illness.

Suggested references

• Croup


• Gender: Male
• Age: 5 years
• Height: Not Available
• Weight: Not Available


• Temperature: 93.8 F/34.3 C
• Blood Pressure: 92/58
• Heart Rate: 111
• Respiratory Rate: 16
• Pulse Oximetry: 97% RA
Signs and Symptoms
Difficulty breathing; stridor; intercostal retractions


• PMH: Croup; dental surgery (tooth pulled yesterday)
• Allergies: None
• Dispatch info: Croup with some difficulty breathing, going on for 3 days
• Lives with parents and three siblings, ages 2, 6 & 8


• None

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