Case of the Month
September 2006

6 month—old male — Shortness of breath

Dispatch

"Aid 271, Medic 3 for a 6 month old male, shortness of breath"

En route your crew discusses the following considerations:

• Croup and epiglottis
• Vital signs in pediatric patients
• Appropriate transport destination for pediatric patients

While responding Dispatch updates that the child has been sick for a few days but has developed severe shortness of breath.

Scene Size-up
You arrive and are met at the front door by the patient’s father; he is very concerned. He leads you to the back porch where the mother has taken the child outside hoping to assist his breathing. As you approach you notice the child is lethargic and has an audible wheeze from a distance. The child is bundled so it is difficult to perform a further assessment.

Initial Assessment
The patient appears lethargic and is working hard to breath. You can hear that he is wheezing even without a stethoscope. The child is brought inside and unwrapped of all the clothing. You are struck by the noticeable retractions at the clavicles and below the xyphoid. His overall appearance is pale to dusky and he has a very weak cry. He feels cool to the touch.

Your partner completes an initial assessment using the Pediatric Assessment Triangle:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Further steps for evaluation?
• Need for ALS care?

Initial Treatment
You decide that the patient is SICK based on his work of breathing and poor skin color. His respiratory rate is also a cause of concern.

You apply a partial non-rebreather mask at 10 liters per minute, and listen to lung sounds finding tight wheezes in all fields. Your team decides to perform a rapid transport and notifies the incoming Medic Unit.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

The patient was immediately classified as sick and high flow oxygen initiated. Due to his size, rapid transport is an excellent option and the mother and child are quickly escorted out to the Aid Car. To assist the child’s breathing the mother is coached to hold him as near upright as is safely possible as an EMT holds a mask near the patient’s face with high flow oxygen. The responding ALS unit is notified of the decision to ‘scoop and run’ and a rendezvous location is established. The ALS unit is updated as to the patient’s status at the same time. 

Once the ALS unit is met the patient is transfer to their apparatus. The Paramedics initialize treatment with nebulized albuterol and began transport. The patient’s response to the therapy was neither positive nor negative, so hospital control was contacted and the medics next attempted racemic epinephrine. This too had no positive or negative results. The decision was made to complete the transport with no other therapeutic measures.

The patient arrived in the emergency room and was evaluated for both viral and bacterial infections, as well as other causes. It was determined that the child was suffering from a severe case of respiratory syncytial virus ( RSV ) for which treatment is primarily supportive. Over the course of a few days the child’s condition improved and he was discharged home.

What is respiratory syncytial virus (or RSV)?
RSV is a very common respiratory virus that can affect either children or adults. It is spread through the transfer of respiratory secretions either directly or onto contaminated surfaces. Avoidance of secretions (through the use of masks and gloves) and hand washing greatly decrease the spread of this, and many others, diseases. There currently is no vaccination for RSV. Like many other respiratory infections, RSV is more prevalent in the fall to early spring months.

The disease often leads to a condition called bronchiolitis which is a swelling and edema of the lower passageways in the lungs. This is a condition that is very similar to the symptoms of asthma, producing the characteristic wheezes and limiting the exchange of air in the lungs. When this develops the patient can become very sick very quickly.

If adults develop the disease the symptoms are usually very mild, however in children, and particularly infants, the disease can be very dangerous. Early stages (the first two or three days) of the disease mimic the ‘common’ cold with runny nose, stuffiness, and slight fever. After this the disease may progress to include coughing, wheezes, difficulty breathing, and rapid heart rate. The infection generally clears itself in seven to ten days; however the symptoms can be severe enough to cause hospitalization, intubation, and even death. Treatment of the disease is mainly supportive. Since it is a viral infection, antibiotic have no effect of the disease. Sometimes inhaled bronchodilators will be used as treatment, however their effectiveness is debatable.

At the sub clinical level most all pediatric reparatory illnesses are treated the same. The patient is triaged as to severity of illness, oxygen is delivered as needed, pharmacological intervention is weighed, and the patient may require transport to a medical facility that can deliver the proper care. Often the nearest hospital is sufficient for treating ill children; however early notification is necessary as some children require transport to a facility that specializes in the treatment of pediatric patients and the local hospital may divert your transport to a better suited medical center.