Respiratory and Fever Emergencies
The febrile child (presentation)
Fever >38
Caused by
Viral infections
Bacterial infections
Immunizations
Overdressing
Teething
Significant in children <3 months old with a temp >38 regardless of other symptoms
Significant in children 3 months - 3 years with
Temp of >38 for more than 3 days or who appear unwell
Temp > 38.9
Children of any age with
Temp >40
Febrile seizure
Fevers for more than 7 days
Fever and chronic illness
Fever coinciding with new onset skin rash
Treatment
Paracetamol 120mg/5ml
o >1 month
o 15mg/kg. SDO.
Midazolam 5mg/1ml
o NAS/IM. 200mcg/kg. Single dose not to exceed 5 mg. Repeated at half the initial dose
(max 2.5mg). 10 min intervals. TMD 10mg.
o IV/IO (CCP). 100mcg/kg. Single dose not to exceed 2.5 mg. Repeated at 5 min intervals.
TMD 10mg.
Retropharyngeal abscess
Formation of an abscess in the retropharyngeal space
Most common prior to 3 years of age (6-12 months). Normally following URTI or trauma
Clinical features
Sore throat and neck
Swollen neck
Difficulty swallowing and speaking
Stridor
Excessive drooling (Mimics signs of epiglottitis)
Epiglottitis
Inflammation of the lining of the cartilaginous tissue that protects the airway during swallowing. Used to
be most prevalent in patients aged 2-6 years. Now rare. Throat should not be examined due to risk of
complete airway obstruction.
Clinical Features
High fever
Sore throat/difficulty swallowing
Stridor/resp distress
Drooling
Hoarse voice
Risk assessment
Any unnecessary disturbance of patient including attempts to lie the patient down, examine the
throat or insert an IV cannula can precipitate total airway obstruction
ETT extremely difficult
Complete airway obstruction develops rapidly within 3-6 hours
Consider alternate causes
o Inhaled foreign body
o Croup
o Bacterial tracheitis
Croup
Virial illness that causes airway obstruction due to inflammatory edema of the subglottis.
Clinical Features
URTI, horse/husky voice, inspiratory stridor, harsh barking seal like cough, widespread wheeze,
increased work of breathing and fever
Affects children 6 months -3 years
Lasts 2-5 days, worse at night
ALOC, hypotonia, cyanosis, pallor all signs of life threatening airway obstruction
Risk assessment
Beware pre-existing narrowing of upper airways (subglottic stenosis or down syndrome
Previous admission with server croup
Bronchiolitis
Viral infection (most commonly RSV) causing acute inflammation of the bronchioles.
Children up to 2 years old, but most common <12 months.
More common in winter months.
Expiratory wheeze, febrile, usually a Hx of URTI.
Normally resistant to bronchodilators as it is inflammatory constriction
Wheeze is due to inflammation, air trapping + increased effort
Mx with oxygen - salbutamol often just increases anxiety and oxygen demand
Over 12 months, with Hx/family Hx of asthma or with eczema consider asthma related bronchospasm.
Bacterial tracheitis
Severe inflammation of the trachea due to bacterial infection with production of thick purulent
secretions and sloughing off damaged tissues.
Peak 3 - 5 years.
Symptoms
Inspiratory/expiratory stridor
Hx of croup-like illness becoming progressively worse leading to sepsis and significant distress
Difficult to differentiate from croup early in the disease
Treatment
Oxygen
Reassurance
Croup
o Adrenaline 5mg NEB
o May increase oxygen demand through anxiety
Transport
o Definitive management for bacterial tracheitis, epiglottitis and retropharyngeal abscess
involve early antibiotics and/or RSI for intubation
Tracheomalacia
Narrowing or collapse of the trachea
Primary
Congenital disorder resulting from underdeveloped tracheal cartilage
Normally improves with age and cartilage development
Seen in normal infants but is more common in Down and DiGeorge syndromes
Secondary
Due to compression of the trachea by vascular rings, tumors or cysts
Stridor in the first weeks of life that persists and gradually worsens
Often misdiagnosed as URTI and croup
Pertussis
Bacterial infection - Bordetella pertussis
Most common in infants <6 months* but can occur up to 5 years and in adolescents and adults
Immunization is only 80% effective
1-2 week URTI prodrome
2-4 week paroxysmal phase – harsh cough followed by vomiting
The classic “whooping” cough is not always present, this is more common in older children
Prehospital Mx:
PPE/infection control, symptomatic Mx
Definitively managed with antibiotics
Pertussis is a reportable disease
Upper Respiratory Tract Infections
Stridor (presentation)
Upper Airway Obstruction
Mild airway obstruction: partial obstruction with adequate airway exchange
Patients themselves will be optimising position (e.g. sitting forward)
Effective cough
Crying or verbal response present
Able to take breath before coughing
Fully responsive
Severe airway obstruction: partial obstruction with inadequate air exchange or complete obstruction
Ineffective cough
Unable to vocalise
Worsening stridor
Quiet or silent chest/unable to breathe
Cyanosis
Decreasing LOC
Hx
Clutching of neck
Sudden dyspnoea, gagging or coughing
Hx of playing with/ eating small items
Exam
Resp distress with stridor, accessory muscle use, recession and paradoxical breathing
Restlessness
Cyanosis
Unconsciousness
Bradycardia
Asthma
Chronic inflammatory, obstructive disorder
Obstruction results from;
Bronchospasm
Inflammation and oedema
Mucous plugging
Smooth muscle hyperplasia and hypertrophy
Increased airway resistance, increased work of breathing, alterations in pulmonary blood flow and
mismatches between ventilation and perfusion causing hypoxia
Gradual onset responds slowly to treatment
Complications
Respiratory compromise
Haemodynamic instability
Electrolyte abnormalities
Risk factors
Prior ICU admissions, prior intubation
3 or more hospital admissions over last 12 months
Currently taking steroids for asthma
Poor compliance with meds
Important pt Hx
Age of onset, frequency, severity, hospital admissions, ICu admissions, previous intubation
Co-existing medical conditions
Allergies
Asthma triggers
Cause of current episode
Duration of symptoms
Medications
Difference in children
Fatigue more easily (rate dependant minute volume, less type 1 muscle fibres in diaphragm…)
Small amounts of constriction produce relatively large proportional airway compromise….
Pneumonia
Suspect in children with fever +/- respiratory distress.
• Often have a cough but swallow the sputum rather than coughing it up.
• Classic signs – impaired percussion, decreased AE and/or bronchial sounds are harder to discern in
small children*
• Diagnosis is often only made via X-ray
Chronic Lung Diseases
Cystic Fibrosis
– Inherited autosomal disease effecting chloride channels in lung
epithelium
– Decreased ciliary clearance of the lungs plus increased innate
inflammatory mediators = increased incidence of bacterial chest
infections
• Chronic Lung Disease of Infancy
(bronchopulmonary dysplasia)
– Usually premature infants <1kg with lung damage from long term
ventilation
– Similar to COPD, have increased airway resistance and reduced
compliance
– Reactive airways prone to bronchospasm
– Higher risk of chest infections
Foreign body – nose, ear, airway
Covered in multispecialty conditions
• Children being inquisitive are more likely to have FB in the ear, nose, airway.
• FB in airway – refer upper airway obstruction per APLS / ARC guidelines (pervious block).
• History is your best indicator.
• When in doubt, maintain a position of comfort, keep parents calm and transport.
Otitis media
Acutely painful
• Diagnosis via otoscopy, but other clues are helpful in young children
– Pulling on ears
– Unsettled +/- fever, unwell without respiratory or UTI symptoms
– Discharge indicates otitis externa or ruptured tympanic membrane
• Mx: Analgesia (paracetamol), supportive cares.
• Will require antibiotics
Anaphylaxis / allergic reaction
