Infant with difficulty breathing

Treatment

• Scene – vitals, assess, temp axillary

• En route – NA • Hospital – none

Disposition

• Response to treatment – no treatment provided.

Authors:

• Elliot Williams, Paramedic Woodburn Ambulance

Editors:

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

Diagnosis

• Fever

Differential Diagnosis

• Febrile seizure (postictal state)

• Upper airway obstruction

• Bronchiolitis

• Sepsis

• Meningitis

• Fever

Patient Workup History

• Both of the patient’s two older siblings have been diagnosed with asthma.

• Caregiver states – Mom states that patient had a 3-4 seconds of not breathing; his face was red and he was stiff. This only happened one time.

• Patient has been a little congested, with a cough; mucus is normal to white.

Physical Exam

• Patient is a very normal-acting 5-month-old. He appears very happy, tracks with his eyes and has good movements.

• GCS – 15

• CBG – n/a

Editor’s Notes

True apnea is defined as a respiratory pause of 20 seconds or greater. It is often difficult to assess the true length of the pause based on history alone, as these events are traumatic for the parents who witness them. This may have been a brief febrile seizure, but was more likely a transient upper airway obstruction from mucus, as the child presents with an acute upper and/or lower airway infection. Respiratory pauses and distress are also associated with RSV bronchiolitis, which is in this patient’s differential diagnosis. I was impressed by how the EMS team was able to calmly reassure the mother with their interaction/communication style.

-Dr. David Spiro

Standard Approach

First steps

• The first step is to ensure that a child with seizure activity is maintaining his or her airway. Once this is ensured, further measures can be taken.

• Establishing IV access is important not only for medications to stop the seizure, but also to administer glucose, if needed, as hypoglycemia is a common cause of seizures in young children.

• Checking a bedside glucose is vital information for prehospital care as well as for care in the emergency department. • Note that a febrile seizure may be the first indication the child is ill

• Febrile seizures in children should last less than 5 minutes, but can last as long as 15 minutes and still be considered a simple febrile seizure. As this child demonstrates, a postictal period follows.

The suggested prehospital approach includes:

• Establish an airway: if patient is maintaining, ensure adequate respirations and saturations. The best way to manage the airway is to stop any ongoing seizures.

• Establish IV access if seizing on arrival, but give first dose of benzodiazepine IN or IM, or rectally if using diazepam.

• Check a bedside glucose

• First-line treatment for persistent seizure activity is a benzodiazepine. This may be repeated if continued seizure activity for 5 minutes after administration.

Suggested References

• Febrile seizures

• Pediatric febrile seizure

Patient

• Gender: Male

• Age: 5 months

• Height: Not Available

• Weight: Not Available

Vitals

• Temperature: 99.7 F/37.6 C

• Blood Pressure: Not Available

• Heart Rate: 170

• Respiratory Rate: 28

• Pulse Oximetry: 98% RA

Signs and Symptoms

Cough, difficulty breathing

History Medical

• PMH: Patient was treated for possible asthma today.

• Allergies: None

• Dispatch info: Difficulty breathing.

Social

• Lives with mom and extended family.

Medications

• Tylenol and albuterol (today)