Ped Croup Uncoop Mother

You are called urgently to the pediatric emergency department to assist in the management of an 7 year old girl who presented from a diverted transatlantic flight from russia with severe stridor. What’s your differential diagnosis and how will you approach the situation?


DDx: Croup, Epiglottitis, Airway foreign body, Anaphylaxis, Bacterial Tracheitis, Infection/Abscess (e.g. periotonsillar abscess, ludwig’s angina, deep space infection), Subglottic stenosis, Tracheo/laryngomalacia, Vocal cord paralysis


ABC and AMPLE approach initially

Immediately assess the patient (personal protective equipment) ensuring oxygen supplementation and full monitoring,

Consider temporization including, Racemic epi, Decadron, Heliox (if FiO2 not as much of a issue), Non invasive ventilation or high flow nasal oxygen

Hx: Stridor (start, duration, prior) severity, infection contacts, Tx to date, LOC changes

Pediatric questions, Developmental history, Immunization status?

Meds/allergies/last meal, PMH, PAH, FH


Exam

Full vitals with full monitoring throughout assessment

General appearance (tripoding drooling, tracheal tugging, active stridor, cyanosis)

Airway

Dysmorphic features, loose teeth, features of difficult airway

Assess for inspiratory striodor/biphasic stridor

Assess for presence of wheeze


Labs

Soft tissue film (epiglottis vs. croup)

Cap gas

+/- cbc/blood cultures depending


Through the help of an interpreter, you learn that the patient has a history of recurrent croup and moderate subglottic stenosis treated conservatively. This current episode began 24 hours prior and has been rapidly progressive. The patient is drowsy but maintaining saturations without supplemental O2. The respiratory rate is 65, and a cap gas reveals a PCO2 of 52. Soft tissue films are consistent with severe croup. How would you proceed?


Candidate should recognize the risk of impending airway loss. Should NOT be reassured by the new information given.

Apply oxygen, Temporize, IV start (might discuss risks/benefits of placing IV), Racemic Epi, Decedron (1mg/kg), Consider NIV/high flow O2 (treating CO2 not SpO2)

Call ENT and ensure present for double setup

Mobilize OR team and prepare OR (This would the ideal location depending on the perceived stability of the child)

Get extra help (AA/RT), Difficult airway cart with Flexible bronchoscopy, Rigid bronc, Videolaryngoscopy, Small ETT (cuffed and uncuffed)


Describe induction and justify

Specific goals are to ensure spontaneous ventilation while maintain deep levels of anesthetia required to prevent laryngospasm and airway loss during airway instrumentation

Use of topical anesthesia and TIVA ideal but volatile anesthesia without topicalization is acceptable

Despite the risks of aspiration, rapid sequence intubation would be contraindicated. One might justify the use of muscle relaxant after the ability to ventilate the patient was determined but this wouldn’t be my first choice (but this is generally acceptable in pediatrics)


While providing some temporizing measures, you inform the mother of the need to proceed urgently to the OR to manage the airway. Through the interpreter she tells you that she “won’t allow you to take her child!” and that all she needs is “better medicine”. She is physically preventing the nurses from attempting the transfer of the patient. How would you manage this situation?


Continue temporizing treatments and ensure all preparations for the OR are continuing.

Attempt to diffuse the situation while constantly assessing the patient’s status for acute deterioration

Through the interpreter assess the reasons for her refusing care

Ensure there is solid understanding (by asking for the mother to repeat the explanations back) of: The status of the child , The risks of not proceeding (rapid airway loss and, ultimately, death), The risks of the proposed intervention, Ensuring explanation that these risks outweigh the risks of inaction, The fact that all other avenues of treatment have been explored

The risks of delayed action.

May be required to call security to help restrain the mother in order to provide the necessary emergency management to the child




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