Soft tissue neck radiograph may reveal a thumbprint

sign of epiglottitis (Figure 49-3), the steeple sign of croup,

or a widened retropharyngeal space seen in retropharyngeal abscess (Figure 49-4). Neck computed tomography

may be required for definitive diagnosis of retropharyngeal

abscess or other deep space infections of the neck causing

airway obstruction.

RESPIRATORY DISTRESS

.&. Figure 49-2. Bi lateral decubitus chest x-rays in a

patient showing right-sided air trapping. Note that on the

left lateral decubitus view (A) the left lung is compressed

as expected. However, when the child is placed right-side

down (B), the right lung remains relatively hyperinflated.

This child was taken to the operating room, where a

peanut was found in the right mainstem bronchus.

Electrocardiogram may reveal decreased QRS amplitude

(pericardia! effusion), electrical altemans (severe pericardia!

effusion or cardiac tamponade), conduction delay (myocarditis), or ST segment and T wave changes (pericarditis).

Figure 49-3. The epig lottis is located by tracing the

base of the tongue inferiorly unti l it reaches the vallecula.

The structure immediately posterior is the epiglottis. If

the epiglottis is enlarged (thumb print) and the vallecula

is shallow, then epiglottitis is present (arrow).

MEDICAL DECISION MAKING

Assess and stabilize airway, breathing, and circulation as a first

priority. Apply pulse oximetry, cardiac monitor, and provide

supplemental oxygen and intravenous (N) fluids immediately. Respiratory arrest means that cardiac arrest will either

be present or imminent. These patients require endotracheal

intubation. Jaw thrust, suction of airway secretions, and use

of bag-valve mask is performed if needed before intubation.

If there are signs of impending respiratory failure (eg,

depressed level of consciousness, decreased response to

pain, agitation, cyanosis despite oxygen therapy, tachy ­

pnea, bradypnea, apnea, irregular respirations, absent

breath sounds, stridor at rest, grunting, severe retractions,

.&. Figure 49-4. Enlarged retropharyngeal soft tissues

showing a retropharyngeal abscess (li nes). The normal

retropharyngeal soft tissue space is <7 mm at C2 and

<22 mm at C6.

Assess

Place IV

Give IV fluid bolus

G ive oxygen

Place on monitor

Signs of impending respiratory failure?

Airway:

• Stridor at rest

• Irregular respirations

· Apnea

Breathing:

• Severe retractions

• Grunting, nasal flaring

• Poor aeration

• Progressive fatigue

Circulation

• Poor color (cyanotic, ashen, mottled)

• Sluggish capillary refill

Mental status

• Decreased level of consciousness

· Agitation

• Decrea sed response to pain

Allow patient to assume position of comfort

CHAPTER 49

Obtain brief history and begin treatment based on suspected disease process

Order labs and imaging as indicated

Continue to reassess patient and obtain additional history

Immediate resuscitation

Clear airway

Assist ventilations

Chest compressions

IV, 02, monitor, IVF

Prepare for assisted

ventilation including

Bipap, endotracheal

intubation

Figure 49-5. Respiratory distress diagnostic algorithm. ABCs, airway, breath ing, and circulation; IM,

intramuscu lar; IVF, I ntravenous fluids.

and use of accessory muscles), direct treatment toward the

suspected cause of distress.

If the patient has known trauma and unilateral decreased

breath sounds, assume a tension pneumothorax and perform

needle thoracostomy initially. For definitive management,

then perform a tube thoracostomy (see Chapter 7). If foreign

body is suspected, perform appropriate maneuvers to relieve

the obstruction based on age and the size of the patient. If

there is severe stridor at rest and fever, assume epiglottitis/

bacterial tracheitis/retropharyngeal abscess and arrange for

emergent definitive airway to be placed in the operating

room with the physician most skilled in difficult airway techniques. In some cases, the ED physician must perform emergent endotracheal intubation in the ED. It is extremely

important to have all difficult airway backup equipment,

including a needle tracheotomy tray immediately available. If

the patient is presenting with a severe asthma exacerbation or

allergic reaction and does not have adequate respiratory

effort, give epinephrine via intramuscular route immediately

while preparing for emergent intubation, if no response to

initial treatment. With severe wheezing not responsive to

bronchodilator therapy alone, if the patient is at an age when

they can cooperate and are still alert, an initial attempt with

positive pressure ventilation with bilevel positive airway pres ­

sure can be very helpful to decrease work of breathing and

prevent need for intubation. New evidence suggests that

high-flow nasal cannula with humidified oxygen can prevent

need for endotracheal intubation in some cases.

If there are no signs of impending respiratory failure

and no immediate life-saving intervention is needed, then

let the patient assume a position of comfort to optimize

respiratory effort and do not agitate. Obtain a brief history

and start treatment based on the suspected disease process.

Order labs and imaging that may help with the diagnosis.