Clinical Practice Case 1

The general assessment consists of your observation (auditory and visual) of the child made during the first few seconds of a patient encounter and focuses on the child's appearance, work of breathing, and circulation (color).

The child is in respiratory distress with increased work of breathing. The main breathing difficulty occurs during the inspiratory phase of the respiratory cycle, which suggests upper airway obstruction. His anxious appearance and pale skin colour may indicate significant hypoxemia or hypercarbia, or both.

You should be worried about this child. He is not clearly in respiratory failure but is at risk. Treatment should begin quickly while you complete your primary assessment.

The most appropriate immediate interventions are to:

• provide oxygen in a non-threatening manner (remember: increased agitation worsens upper airway obstruction) 
• place a pulse oximeter
• begin appropriate therapy with nebulized epinephrine or racemic epinephrine

Allow the child to remain in a position of comfort (such as on the mother's lap) rather than place the child on a stretcher to minimize agitation.

Although the PALS course suggests a linear approach to patient evaluation and treatment (Evaluate - Identify - Intervene), providing care for the patient often involves a mixture of these interventions.

Your initial actions should focus on life-saving or stabilizing interventions. Your later actions will likely be more focused on specific treatment. Base subsequent treatment on further assessment and categorization of the patient's condition with consideration of the likely etiology. These assessments and revised approaches to therapy occur continuously during your patient encounter.

The primary assessment comprises an ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) evaluation with vital signs (including pulse oximetry).

This toddler has upper airway obstruction. Based on the history, it is most likely from a viral infection leading to croup. You should consider that a foreign-body airway obstruction (FBAO) may be present, but the history of relatively slow onset and gradual worsening of symptoms makes an FBAO unlikely. The high-pitched upper airway sounds also suggest that the upper airway obstruction is at a level just below the vocal cords (subglottic). Because the child is now watching you and does not appear as anxious, you note that his respiratory function and clinical condition have improved in response to oxygen administration.

Appropriate next steps include administration of nebulized epinephrine or racemic epinephrine to reduce upper airway obstruction. Administration of oral dexamethasone would also be appropriate. You should carefully observe this child for worsening symptoms and the possible need for additional intervention. You can now obtain a more complete history and perform a more thorough exam. The exam (secondary assessment) may be deferred until the child is breathing more comfortably after the epinephrine inhalation treatment.

Relevant history questions include asking if the child was premature, was mechanically ventilated (which increases the risk of upper airway injury, predisposing to upper airway obstruction with subsequent infections), or has had episodes of croup in the past. A history of croup suggests an underlying airway problem (eg, subglottic stenosis, an airway hemangioma, or laryngeal papillomatosis). At present, there is a little indication for laboratory studies, such as an arterial blood gas (tertiary assessment).

Respiratory failure is defined as inadequate oxygenation, ventilation, or both. Pulse oximetry does not evaluate the effectiveness of ventilation (ie, elimination of carbon dioxide). Children may develop hypoventilation with significant hypercarbia, yet if they are receiving supplementary oxygen they may maintain normal Sp02. Although a normal Sp02 is somewhat reassuring, the child still needs careful assessment to determine if ventilation is adequate.

Many conditions can cause upper airway obstruction. The child's symptoms can give clues to the site of the obstruction. For example, high-pitched inspiratory stridor is seen with croup; snoring inspiratory sounds are heard with a floppy pharynx and tongue occlusion. Prominent retractions and intermittent complete upper airway obstruction can be seen in a sleeping infant or child with enlarged tonsils and adenoids. Foreign bodies, peritonsillar and retropharyngeal abscess, laryngomalacia, and airway hemangiomas and polyps are other examples of conditions causing upper airway obstruction.