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??

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