Rosen & Barkin's 5-Minute Emergency Medicine Consult (681 page)

DIAGNOSIS

• Breathing difficulties
  
• Audible stridor (worsens with feeds, crying, and on lying supine)
  
• Muffled
  hoarseness
  “Hot potato” voice in adults
  
• Feeding difficulties in infants (amount of feeds and regurgitation with GERD)
  
• Apneas and cyanotic attacks
  
• Antenatal, perinatal, and birth events (e.g.. resuscitation at birth with intubation)
  
• Anxiety
  
• Cough
  
• Drooling
  
• Sore throat
  

• Tachypnea
  
• Dyspnea
  
• Dysphagia
  
• Fever
  
• Respiratory distress, worse with agitation
  
• Nasal flaring, intercostal retractions, subcostal indrawing
  
• Paradoxic diaphragmatic movement (late finding)
  
• Audible stridor (inspiratory/biphasic stridor)
  
• Cyanosis
  
• Trismus:
  
  • Peritonsillar abscess, retropharyngeal abscess, Ludwig angina
    

• Visualization of the upper airway:
  
  • Radiographic if symptoms very mild; be careful!
    
• Direct visualization in OR with a surgeon prepared to perform a cricothyrotomy or tracheostomy is the safest approach.
  

These tests are not helpful and thus avoidable; may upset a child even more.

Radiograph of lateral and posteroanterior neck and chest:

• Not essential
  
• Only done in extremely mild cases or when there is suspicion of foreign body aspiration
  

• Fiberoptic laryngoscopy:
  
  • Should be performed with an intubating fiberoptic laryngoscope in a setting where a rapid surgical airway can be obtained
    
• Direct laryngoscopy:
  
  • Diagnostic study of choice
    
  • Should be performed in a setting where a rapid surgical airway can be obtained
    

• Stertor:
  
  • Pharyngeal obstruction while wheezing
    
• Bronchospasm
  
• Malingering (patient breathing against a closed glottis)
  

TREATMENT

• Keep child calm, with mother if possible.
  
• Supply blow-by oxygen.
  
• Maintain adequate airway.
  
• Use bag-valve-mask (BVM) if respiratory status deteriorates.
  
• Intubate if BVM ineffective.
  
• Provide rapid transport with ED notification.
  

• In children: Avoid agitation. Supply blow-by oxygen.
  
• Use 100% nonrebreathing-type face mask
  
• Pulse oximetry to check oxygen saturation and monitoring of vitals.
  

• Avoid agitating child.
  
• Watch for rapid deterioration of respiratory status.
  

• Airway management:
  
  • Stridor comprises a difficult airway passage:
    
    • Be prepared to create an airway surgically before intubation.
      
    • If time permits, perform intubation in OR with surgeon and pediatric anesthesiologist present.
      
    • Intubate with tube 1 or 2 sizes smaller than would be normally used.
      
• Oral awake intubation:
  
  • Ketamine induction
    
  • Patient is sedated but continues to ventilate during procedure.
    
• Avoid blind nasotracheal intubation.
  
• Oral intubation is preferred initially. After oral intubation the oral tube is replaced by a nasal tube of the same size.
  
• Provide surgical airway if intubation fails or sudden deterioration in respiratory status occurs.
  
• Postintubation ceftriaxone in cases of infectious cause
  
• Sedation/paralysis for duration of intubated status after airway is secured.
  
• Extubation could be attempted when an air leak develops around the tracheal tube, which can take around 2–10 days.
  
• Controversies:
  
  • Heliox therapy
    
  • Racemic epinephrine therapy
    
  • Early intubation
    

• Atropine: 0.02 mg/kg IV
  
• Ceftriaxone: 1–2 g IV
  
• Diazepam: 2–10 mg IV (peds: 0.2–0.3 mg/kg)
  
• Etomidate: 0.3 mg/kg IV
  
• Fentanyl: 3 μg/kg IV
  
• Ketamine: 1–2 mg/kg IV or 4–7 mg/kg IM
  
• Lidocaine: 1.5 mg/kg IV
  
• Midazolam: 1–5 mg IV (0.07–0.3 mg/kg for induction)
  
• Vecuronium: 0.1 mg/kg IV
  
• Nebulized epinephrine: 1 mL of 1:1,000 diluted to 5 mL with normal saline
  
• Dexamethasone: 0.15 mg/kg oral/IV
  

FOLLOW-UP

All cases of stridor that are not completely resolved during the ED course mandate admission of patient to hospital.

Stridor fully resolved or identified as a nonstridorous abnormal breathing sound.

Consultation with an otolaryngologist or a pediatric surgeon prior to airway visualization

• Attempting visualization of the airway without the backup needed for an emergency tracheostomy is a pitfall.
  
• Laryngoscopy findings determine the indications for other complementary exams such as barium swallow, polysomnography, echocardiography, CT, or magnetic resonance scans of neck and thorax.
  
• Patients, especially children with stridor, often have associated abnormalities involving respiratory tract which mandates not only endoscopic exam of the larynx, but also the tracheobronchial system.
  

• Boudewyns A, Claes J, Van de Heyning P. Clinical practice: An approach to stridor in infants and children.
  Eur J Pediatr.
  2010;169(2):135–141.
  
• Daniel M, Cheng A. Neonatal stridor.
  Int J Pediatr
  . 2012;2012:859104.
  
• Halpin LJ, Anderson CL, Corriette N. Stridor in children.
  BMJ.
  2010;340:c2193.
  
• Mellis C. Respiratory noises: How useful are they clinically?
  Pediatr Clin North Am
  . 2009;56(1):1–17, ix.
  
• Walaschek C, Forster J, Echternach M. Vocal cord dysfunction without end?
  Klin Padiatr
  . 2010;222(2):84–85.
  

CODES

• 748.2 Web of larynx
  
• 748.3 Other anomalies of larynx, trachea, and bronchus
  
• 786.1 Stridor
  

BASICS

• Bleeding into the subarachnoid space and CSF:
  
  • Spontaneous:
    
    • Most often results from cerebral aneurysm rupture
      
    • Aneurysms that occur are more likely to rupture (>25 mm).
      
  • Traumatic:
    
    • Represents severe head injury
      

• Incidence is 6–16 per 100,000 individuals.
  
• Affects 21,000 in US annually
  
• Associated mortality in 30–50% of patients
  
• Uncommon prior to 3rd decade; incidence peaks in 6th decade
  

• Previous ruptured aneurysm who have other aneurysms
  
• Family history
  
• Hypertension
  
• Smoking
  
• Alcohol abuse
  
• Sympathomimetic drugs:
  
  • Cocaine, methamphetamine, and ecstasy (MDMA) use
    
• Gender (female:male 1.6:1)
  

• 3–7-fold increased risk with 1st-degree relatives with subarachnoid hemorrhage (SAH)
  
• Strongest genetic association represents only 2% of SAH patients:
  
  • Autosomal dominant polycystic kidney disease, Ehlers–Danlos type IV, familial intracranial aneurysms