The Value of Restraint

     It's been a long day, but by 2300 hours Attack One is back at the station. The crew is about to eat its long-since-cold dinner when someone starts banging on the front bay doors. It's a young mother with her child, who is making a lot of noise as he breathes. The crew brings the pair into the building. Because of the child's distress, they ask the mother to carry him into the patient compartment of the ambulance unit in the station. There they place the child on oxygen and prepare a nebulizer treatment.

     The child is 2, and his mother says he's been having trouble breathing for the last hour. He was ill the evening before, but seemed to get better during the day. He fell asleep, but his mother noted him making more and more noise as the evening went on, and finally she decided to take him up the street to the fire station. He's a generally healthy child, and no one else in the home has been ill.

     The toddler does not want to leave his mother's arms, and barely lets the crew give the nebulizer to mom to hold in place. He is using his chest and neck muscles to breathe and seems to have a barking cough. When the paramedic listens to the child's lungs, he hears a lot of airway noise, including wheezes. The child is not drooling, and his mom says he drank a little juice before they walked to the station. He has not vomited or choked on anything she's aware of. Finally getting the child to cooperate, the crew places a pulse oximeter on his finger, and finds his oxygen saturation to be in the high 80% range.

     A 2-year-old male in respiratory distress. He feels warm to the touch.

     Airway: Child is making noise with respirations and has a barking cough.

     Breathing: In moderate distress in an upright position. Improves after nebulizer treatment.

     Circulation: Normal capillary refill, pink skin.

     Disability: Normal toddler behavior, no deficits.

     Exposure of Other Major Problems: Patient doesn't want to leave his mother, but can't be transported safely in her lap.

     Allergies: None.

     Medications: Over-the-counter cold medication; immunizations not up to date for age.

     Past Medical History: No prior medical problems or history of pneumonia.

     Last Intake: No recent food intake.

     Event: Severe respiratory distress, with barking cough and wheezing. The crew communicated the possibility of epiglottitis to ED staff.

     The mother here gave a clue that education was needed regarding restraining the child in her own car: When she said she usually had the child sit on her lap as she drove, she revealed a need for a follow-up visit to install a child safety seat and educate her on its proper use. There are other general safety opportunities that may be appropriate to review with parents when EMS is in a child's home and there are no pressing emergency medical needs. Toddlers face risks from open upper-floor windows, unsecured cabinets with chemicals or medications inside, stairs and dangerous cords and electrical outlets. EMTs providing service in homes where toddlers are present can observe such dangers and suggest measures to prevent later tragedies.

     There's no need to delay transportation any longer, so the transport crew sets the patient up for the 15-minute ride to the hospital. The child is most comfortable in an upright position, so the child safety seat is attached to the patient cot, and the mother will be secured at the head of the cot in the captain's chair.

     The mother asks that the child be allowed to ride to the hospital in her lap. "He's so comfortable sitting here with me," she says. "Why can't he just stay here for the ride? He always sits on my lap in the car."

     "Sorry, ma'am," a crew member tells her, "but every child must be safely buckled in the unit before we can move, especially when we need to drive quickly to the hospital. Let's buckle you in, and I'll buckle myself in, and together we'll let him know it's OK to be in our seats with our belts on."

     Both adults strap in for the ride. Mom will hold the mask on the child. The driver uses lights and siren en route, and throughout the trip the paramedic reassures the child that he's doing well.

     About a mile from the hospital, there's a sudden jolt. The ambulance abruptly turns hard to the left, tires squealing against the pavement. Simultaneously, the driver yells, "Crash!" The nebulizer flies from the mother's hands, and every bit of loose equipment in the compartment and on its shelves relocates. The vehicle comes to a quick stop, but without any sudden impact or the terrible sound of a collision.

     "Is everything OK in the back?" the driver immediately asks.

     "We're all in place, and nothing flew," the paramedic replies. "What happened?"

     An elderly driver had made a sudden turn in front of the ambulance, the driver explains, attempting to pull into a parking lot, and never seemed to see the emergency vehicle, despite its lights. The ambulance operator had narrowly avoided a major "t-bone" collision, and managed not to strike anything. The patient compartment had fortunately been completely secured before transport, and all three cabin passengers restrained. The monitor, oxygen bottles and other large pieces of equipment had been secured in their brackets. All the loose materials in the cabinets were now out of place, but the only object that flew in the patient compartment was the nebulizer and mask.

     The crew reassures the mother and child, then completes the remaining trip to the hospital. The ED is prepared for the child's arrival: The respiratory therapist resumes the nebulizer treatment, and the emergency physician quickly utilizes x-rays of the child's neck and chest to exclude the diagnoses of epiglottitis and pneumonia. The crew completes its documentation, then gets to work reorganizing the back of the medic and completing a near-miss report. This extra time at the ED allows them to come back later to explain the event to the mother. By that time, the ED staff reports, the patient is breathing much more easily, his airway noise gone completely.

     The mother is grateful for the clinical care and concern shown for her child, but is most appreciative that they were not injured in the near-collision. The crew explains what happened with the other driver, and that incidents like this were why they insisted that everyone be secured in belts in their vehicle—a safety practice that certainly paid off. They also ask that the mother come by the station in the next few days to have her child safety seat inspected, in case a similar event were to occur while she was driving her own car. From her reaction, it's apparent to the crew that the mother has no safety seat in her car. Without directly confronting her on the issue, they ask if they can have their safety officer contact her the next day, since the child would likely be released from the ED that evening.

     Learning Point: Toddlers are at risk for a set of illnesses that can cause respiratory distress. Children in this age group often have great anxiety about strangers, which can be exacerbated when they're ill. They often have great resistance to being restricted, whether in spinal immobilization or vehicle restraints. Nonetheless, for all involved, there are great benefits to using adequate restraints, which can prevent tragedy even in near-miss events.

     Toddlers are at risk for a variety of illnesses that can cause respiratory distress and a croupy cough. In general, a loud barking cough means the problem is in the trachea or larynx. First consider a foreign object, such as an aspirated bead, coin or other small item. If the child has been ill or has a fever, an infectious illness is usually the cause. Viral or bacterial illnesses can affect both of these airway elements. Over the years, bacterial epiglottitis has been a major concern. There are fewer cases now, due to childhood vaccines, but it still can occur. Epiglottitis classically manifests with fever, upper airway noise and cough, drooling, and a very ill-appearing child. There's a great risk that a child with epiglottitis can suddenly lose his or her airway; if so, placing an endotracheal tube can be extremely difficult. A child with a classic presentation such as this should be transported safely, with moist oxygen administered through a "blow by" mask, to an emergency department prepared to manage a potential airway crisis.

     Croup, the case here, is a much more common illness, caused by a virus, that results in a barking cough, greater breathing effort and a low-grade temperature. Croup is a disease of the early evening, often worsening between 1900 and 2400 hours, as with this child. Croup and the croupy cough are caused by swelling in the soft tissues of the larynx and trachea, due to the viral infection. Adults get the same type of swelling with upper respiratory viruses, but the adult airway has a wide enough diameter that the airway noise does not occur with a cough. That barking cough is almost always heard in children.

     The treatment for croup is reducing the soft tissue swelling, which can be done by having the child breathe cool, moist air. Hospital treatment will include steroids like prednisone, which reduces the soft tissue swelling over hours, and rapid relief for children in distress by epinephrine in mist form. Racemic epinephrine is a dilute preparation for use in nebulizers. Inhalation of epinephrine causes local vasoconstriction and reduced swelling of the upper airway, as well as systemic beta action from absorption and effects on bronchial smooth muscle that may relieve bronchospasm. Albuterol mixed with saline will often have a similar positive clinical effect, particularly if there is some bronchospasm present, as with this child. Antibiotics are not used in croup, as it is not a bacterial disease. Most children with croup can be treated in the ED and released home.

     This case demonstrates the many benefits of immobilizing a child in an appropriate child seat when transporting. Having a calm and reassuring parent in the patient cabin, also appropriately restrained, will allow the child to remain as controlled as possible while treatments are delivered. Toddlers often respond well to soft, cuddly toys—consider having one available. But always apply appropriate vehicle restraints to children being transported, to avoid an outcome no toy can overcome.

     James J. Augustine, MD, FACEP, is deputy chief-assistant medical director for Washington, DC, Fire and EMS and a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.