Clinical Case 19: If it barks like a seal, is it a seal?

Winter in any paediatric ED means – flu season, bronchs, croups, URTI etc etc.  It can be tough to pick the true sick kid out of the haystack of cranky, viremic ones.  This case illustrates this point beautifully!

10 month old girl with a classic story – URTI sxs for 2 days, then woke at midnight with a harsh / brassy cough, hoarse / weak cry and stridor… too easy:  croup.  Presents the next AM to ED.   Tired looking mum is happy to take her home and try a dose of dexamethasone this evening.  (See a couple of studies to support this from NEJM, Bjornson [0.6 mg/kg]  and our own West Aussie Gary Geelhoed, PMH in the BMJ [0.15 mg/kg]).

So I saw this kid the next day, had tried the dex and was not much different, rough night, harsh cough, but looked better by sunrise.  On examination – snotty nose, red throat, chest clear, no stridor, OBs all OK, low-grade fever.  My thoughts – likley this is croup, she was just a bit smaller than the average croup kid, so needed another day / more dex to get her through.  No story or signs to suggest a FB.  So I sent her home with another dose of dexamethasone, return if the stridor returns / increasing distress etc….

I was expecting to see her again (if at all) around midnight, but no…  3 hours later mum brings her back – stridor, fever, marked chest wall recession… hmmmm… not how croup should behave.   So we tried the dose of dex she was going to have later, and watched her closely.

I think this is a crucial point in Paediatric decision-making.  We see a lot of  “syndromes” of common illnesses (asthma, bronchiolitis, croup, gastro, otitis….) and we “know” these well.  Recognising a variation from these patterns is a vital clue when trying to spot the sicky in the viral haystack.

 Back in ED – I was called away to gas an ectopic.  Halfway through the case I got a call from my colleague – she is not doing well, working hard and stridor worse, fever spiking.   So we went for the adrenaline neb (Cochrane Review of Adrenaline in Croup – “it works, for a while”), which predictably helped.. for a while, then she became dyspnoeic again, so another round of adrenaline was given and a call for help went out!  We were in trouble.  I do a bit of Paeds Anaesthesia but tubing a 10 monther with an oedematous airway is not in my repertoire usually!

Bacterial tracheitis   (Staph / Strept) is most likely in a vaccinated child. Consider epiglottitis in a kid from overseas or non-vaccinated for Hib.  Other rareities: tumour, vascular malformation, retropharyngeal abscess, FB.


There is no good answer. I have asked a number of Paeds Anaesthetists and gotten a range of answers. Spont ventilating gaseous induction? Nasotracheal intubation?  Controlled RS intubation post adrenaline neb ? Äwake fibre optic” = impossible in an infant.  What about ketamine? 

Please tell me, how would you do it??


  1. I’ve watched (emphasis on watched!) people tube kids twice with a tracheitis, both older than 10 months, but both just went for an old fashioned induction and laryngoscope and and no probs but with ENT present.

    i’m told (emphasis on told!) that the airway is OK in a tracheitis cause the pathology is below the cords

    i suppose it’s in a true epiglotitis that the shit hits the fan.

  2. Casey Parker says

    Thanks Andy
    You are probably right. Problem is you might get a nasty surprise when you look. Epiglottitis is rare, but there is no good way to say when it is happening. Maybe a lateral neck XR? We did one in this case

  3. Minh Le Cong says

    Hi Casey and Andy

    talk about a tough case!
    How did you manage to get an IV in this kid?!

    Anyway assuming that you do..we can discuss about if you don’t have an IV situation a bit later…

    There are two reasonable options:
    1. Double setup – your best orotracheal intubator with Jedi Like skills having a RSI attempt from the top and your best surgically skilled provider prepped and ready to make a hole in the neck..either a needle cric or tracheostomy or open cric but good luck in a 10 month old.

    2. Spont breathing induction with sevoflurane, or propofol TCI, or ketamine. Most places remotely do not have TCI pumps but some have the modern pumps that do everything incl TCI. Its a good idea to become familiar with your pump and if it can do TCI. If you don’t have it you can guess and manually bolus in propofol and /or ketamine but then it depends on your experience and your nerve.

    Bottom line : Do what you are familiar with. I suspect you just RSI’d the kid and shat yourself for a few seconds till you got the tube in

  4. Having received a few similar cases in PICU – some handled masterfully, others less so, I had a think about how I would go about things in a LITFL post appropriately titled ‘Time to tighten those sphincters’:

    Our options (echoing Minh) are either:
    1. tube with spont vent if you have the skills and equipment, or the time until they become available (i.e. expert help arrives, and there is time to get to theatre)
    2. RSI – prepare for failure and don’t try any halfway measures – maximise your intubation chance on the first attempt, if unsuccessful cut the throat (in a child I’d do a needle cric)

    … can’t wait to find myself in that situation… yeah right
    Chris Nickson

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