This case is written by Dr. Jonathan Pirie. He is a staff physician in the Division of Pediatric Emergency Medicine and Associate Professor at the University of Toronto. Dr. Pirie is also the Director of Simulation for Pediatric Emergency Medicine and the Simulation Fellowship program. His simulation interests include development of core curricula for postgraduate training programs, in-situ team training, and mastery learning with competency based simulation for trainees and faculty in pediatric technical skills and resuscitation.
Why it Matters
While croup makes stridor a relatively common presentation in the Pediatric ED, today it is quite rare to have a child with stridor who requires definitive airway management. It is exceedingly rare for an Emergency physician to need to proceed to cricothyroidotomy on a child. This case highlights the following:
- The initial management steps for a child with undifferentiated, severe stridor
- The need to call for help early
- The steps required for a needle cricothyroidotomy and the equipment necessary to ventilate a child after this procedure is performed
You are working in the ED, and your team has been called urgently to see a 2-year-old old boy with difficulty breathing. The patient was brought in by his mother, who states he’s had a 2-day history of runny nose. Today he developed a barking cough with fever, and is “breathing with a funny noise.”
The ED team is called to manage a 2-year-old boy in severe respiratory distress with stridor and hypoxia. Initial management steps (humidified O2, nebulized epinephrine and dexamethasone) fail to improve the patient’s respiratory status, and the team must prepare for a difficult intubation. They will encounter difficulties with both bagging and passing the endotracheal tube due to airway edema, which will necessitate an emergency needle cricothyroidotomy.
This case is written by Dr. Ahmed Taher. He is an Emergency Medicine resident at the University of Toronto and a Masters of Public Health Student at Johns Hopkins University. He developed his appreciation and excitement for simulation while previously employed as a Primary Care Paramedic for York Region EMS.
Why it Matters
Anaphylaxis is a fairly common presentation to the ED. However, it is rare to see truly severe anaphylaxis. This case exposes learners to the most feared complication of anaphylaxis – angioedema requiring surgical airway management. In particular, it highlights:
- The importance of initiating early treatment for anaphylaxis with epinephrine (and removing ongoing allergen exposure, if possible)
- The need to intubate early in patients with signs of airway compromise not immediately responding to epinephrine
- The fact that the “decision to cut” is crucial (and arguably the most challenging part of a surgical airway)
- The steps required for a successful cricothyrotomy
You are working a night shift at your local Emergency Department. You are called STAT to the bedside of a patient in the department who was seen by your colleague earlier and has recently been started on IV ceftriaxone for a pyelonephritis. You recall from handover that this is a 45-year-old previously healthy female patient with a diagnosis of a UTI two weeks ago, who returned after failing treatment and was diagnosed with pyelonephritis today. The nurse tells you she started the IV antibiotics and fluids 20 min ago, and then started to experience respiratory distress and a full body rash.
A 45-year-old patient who has already been seen in the ED begins treatment for pyelonephritis with IV antibiotics. Soon after initiated, she develops stridor and respiratory distress, as part of an anaphylactic reaction. The team is called into the room to assess the patient. After standard anaphylaxis treatment is given, the airway is still of concern. Intubation attempts are not successful and the patient will need a surgical airway.
ECG for the case found here:
(ECG source: https://lifeinthefastlane.com/ecg-library/sinus-tachycardia/)
CXR for the case found here:
(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female)