Crashing Hard and Fast

Winter seems an appropriate time to delve into the world of pediatric respiratory disorders, specifically upper-airway disorders, and snot. Yes, snot—kids are full of it, and it makes them laugh and giggle. 

The parents of the congested 1-month-old don’t find it so funny. They cannot figure out why nothing they do makes their baby better, and little do they know this could go on for weeks. Finally reaching their breaking point, they call EMS and enter the healthcare system. 

We remember from our training that kids are robust and resilient. So why is respiratory distress such a big deal? Respiratory distress is the leading cause of cardiac arrest in children. Hypoxic-asphyxial arrest is the most common cardiac arrest in children and frequently caused by airway obstruction or depressed respiratory drive.¹

Children will compensate for a long time, sometimes hours or days. Nonetheless, when they finally crash, they crash hard and fast. At this point we are often behind the eight ball and have a tough time recovering. According to researchers led by the University of Pittsburgh’s Ericka Fink, MD, the out-of-hospital cardiac arrest survival rate for children has mostly remained unchanged over the last several years, hovering in the 6%–10% range.² 

Initial Contact

What does respiratory distress look like in children? They can have an elevated or decreased rate and an unusual respiratory pattern. Although we often caution students against using tachypnea as the sole indicator of respiratory distress, children in stressful situations often become tachypneic when excited.

Here is where our assessment skills come into play: Use your doorway assessment and the pediatric assessment triangle and take note of the quality of their breathing. We often note nasal flaring and abnormal breath sounds such as wheezing and stridor. If their presentation is more toxic, we can often hear them from outside the room or notice significant retractions and abnormal positioning, such as a tripod position in an attempt to keep their airway open. 

When you approach a child in respiratory distress, get down on their level and approach slowly. Use a parent to ease access, so the child doesn’t feel you’re a threat. Try to use a calm, soothing approach and continue your visual and audible assessment without laying hands on them. What do you see and hear? Retractions often appear above the clavicles, tugging at the trachea, with the intercostal muscles, and in genuinely severe cases we might think their sternum is going to touch their spine.

With the help of a parent, try to get the child’s shirt open or off for a proper visual inspection of their chest. Listen for lung sounds first without a stethoscope and then with one. It is often useful to show the child what you’re going to do by demonstrating first on yourself or a partner. Let them listen as well. It will build trust and calm fears. Keeping a pediatric patient in respiratory distress calm can be a significant hurdle, but it will make assessment and treatment significantly easier. 

Grunting and head bobbing are frequently ominous signs. Generally respiratory and cardiac arrest soon follow. If you notice these signs on your initial assessment, it might be time to pick up the pace and be prepared for more significant airway interventions. 

The Upper Airway

Typically abnormal breath sounds can be broken down into three different categories: upper airway, lower airway, and “lung tissue disease,” as our friends at AHA like to call it. In this discussion we will concentrate on the upper airway. Aberrant upper-airway lung sounds include stridor on inspiration, a barking or “seal” cough, and generalized hoarseness when speaking or crying.

These sounds are vital indicators that tell us we have upper-airway obstruction. The typical differential with upper-airway obstruction in pediatrics will include foreign-body obstruction, croup, pertussis, and epiglottitis. 

From the time small children figure out how to get their hands to their mouths, they start exploring their surroundings with their mouths. There are occasions when a plastic building block or doll shoe may find its way into the upper airway. If Barbie lost her shoe down this precious baby’s right main stem, they’ll need to spend some time with a local pulmonologist to fetch it.

The best course of action here is to keep your patient calm, help them maintain their airway on their own, and not intervene unless necessary. You might think you can do the hero maneuver and extract it with your magical Magill forceps skills, but odds are, in an uncontrolled environment with a conscious, breathing child, you will do more harm than good. 

If instead you’re looking at a “disease process” and not a foreign body, most frequently it will be either croup or pertussis, commonly referred to as whooping cough. Although the terms are frequently used interchangeably, these disease processes are not the same. They are both infectious and most commonly occur in small children with smaller airways. 

Croup is a viral infection that typically strikes children from 6 months up to 6 years of age and affects roughly 5% of that age group every year. According to the Mayo Clinic, most cases of croup are treated at home with symptomatic comfort care.³ Cool-mist humidifiers have been shown to be beneficial in reducing symptoms and irritation. In the back of the ambulance, we can often nebulize saline for the same effect. If the case persists longer than five days or so, a physician may opt to treat with steroids. 

Pertussis, on the other hand, is bacterial and can affect us at any age. According to the CDC it is most prevalent in children under 1 year, followed by children between 7–10.⁴ Treatment for pertussis is often time-dependent, as it is a bacterial infection and can rapidly get worse. Early identification and treatment with antibiotics are critical. The CDC recommends considering treatment before lab results have been completed.

In the prehospital environment, we again find that treatment with cool mist or nebulized saline and rapid but calm transport to the nearest appropriate pediatric facility will be our treatment of choice. 

A more frightening prospect to the prehospital provider is epiglottitis, also known as supraglottitis. Hib, or Haemophilus influenzae b, is a common bacterial cause of epiglottitis. According to the Mayo Clinic, “Routine Hib vaccination for infants has made epiglottitis rare, but epiglottitis remains a concern.”⁵ 

Epiglottitis can be caused by either a viral or bacterial infection, or in some cases a combination of the two. It can also be caused by trauma to the upper airway. Although rare, epiglottitis is considered a true life-threatening emergency and must be treated emergently. Remember that with epiglottitis, aggravation or stimulation of that swollen area can cause the airway to close immediately.

As a rule these patients need to be taken to the OR, where personnel will have the ability to perform a rapid-sequence or surgical airway if the first attempt fails. As prehospital providers our best intervention may be no intervention at all: If the patient is maintaining their airway and adequately perfusing their brain, the less direct intervention we do, the better. 

Less-Common Causes

Of course there are other, less-common causes of upper-airway obstruction. Things to keep in mind include upper-airway abscesses, pharyngeal, peritonsillar, or retropharyngeal; congenital malformations; tumors; or even just lots of thick secretions. 

Respiratory syncytial virus (RSV) season, fall and early winter, will turn that lovable 3-month-old into a never-ending snot factory. Babies cannot breathe the way they want to because they are pouring snot. They cannot eat because they cannot breathe, and they cannot sleep. It is all because of the snot! There isn’t a magic bullet to cure RSV; it will persist for a month to six weeks. The younger its victim is, the more likely they will need to be admitted to the hospital because they cannot protect their airway and must receive around-the-clock comfort care and frequent suctioning.⁶ 

Prehospital pharmacological intervention for upper-airway obstructions is relatively limited. Racemic epinephrine is still considered the first-line emergent pharmacologic treatment for inspiratory stridor, steroids second, and pathogen treatment as the definitive long-term care. Remember the effectiveness of steroids is time-dependent. For example, IV dexamethasone will reach peak serum levels roughly one hour after given.⁷

Steroids given in the prehospital environment will reduce patients’ length of stay in the emergency department.⁸ We will not see the effects before arrival at definitive care. In NASEMSO’s Model EMS Clinical Guidelines published earlier this year, evidence showed the use of 5 ml of 0.1 mg/ml of nebulized epinephrine is beneficial in patients with respiratory distress with signs of stridor at rest.⁹ 

Conclusion

The takeaway for the prehospital provider is that an upper-airway obstruction of any type is an actual medical emergency. The most important treatment is to remain calm and use caution. Move the patient slowly and prevent any extraneous stimulation.

Administration of cool humidified oxygen or medical air has historically been used to help relieve some of the discomfort of upper-airway obstruction, and some believe it may even begin to reduce associated swelling, although definitive research is limited and the new NASEMSO model guidelines recommend against it. Keeping our young patients calm and reducing their crying can also help prevent the worsening of symptoms. 

Remember, you’re comfortable in your environment. But you’re about to take a scared child into the back of your scary ambulance, strap them to a bed without their parent, and go flying down the highway. Slow down, allow a parent to sit next to the patient on the CPR seat, and take a calm, easy drive to the hospital.  

References

1. Varvarousi G, Xanthos T, Lappas T, et al. Asphyxial cardiac arrest, resuscitation and neurological outcome in a Landrace/Large-White swine model. Laboratory Animals, 2011; 45(3): 184–90.

2. Fink E, Prince D, Kaltman J, et al. Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America. Resuscitation, 2016; 107: 121–8.

3. Mayo Clinic. Croup, www.mayoclinic.org/diseases-conditions/croup/diagnosis-treatment/drc-20350354.

4. Centers for Disease Control and Prevention. Pertussis (Whooping Cough), www.cdc.gov/pertussis/index.html.

5. Mayo Clinic. Epiglottitis, www.mayoclinic.org/diseases-conditions/epiglottitis/symptoms-causes/syc-20372227.

6. Mayo Clinic. Respiratory syncytial virus (RSV), www.mayoclinic.org/diseases-conditions/respiratory-syncytial-virus/symptoms-causes/syc-20353098.

7. Prescribers’ Digital Reference. Dexamethasone sodium phosphate—Drug Summary, www.pdr.net/drug-summary/Dexamethasone-Sodium-Phosphate-Injection--USP-10-mg-mL-dexamethasone-sodium-phosphate-1725.

8. Bekmezian A, Fee C, Bekmezian S, et al. Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma. Pediatr Emerg Care, 2013 Oct; 29(10): 1,075–81.

9. National Association of State EMS Officials. Model EMS Clinical Guidelines, https://nasemso.org/projects/model-ems-clinical-guidelines/.

Roger Smith, NRP, is pediatric EMS coordinator at the Children’s Hospital at OU Medicine in Oklahoma City and adjunct faculty for the OSU-OKC paramedicine program. He is a member of the National Association of EMS Educators.