354 Paediatric Emergencies
STRIDOR2 Onset of symptoms occurs over 6–12 h and may rapidly progress to airway
obstruction. These include:
(i) High fever: usually the first symptom.
(ii) Inspiratory stridor: softer than with croup.
(iii) Severe sore throat: associated with dysphagia, inability to swallow
saliva and drooling.
(iv) Muffled voice. Cough is usually absent.
3 The child looks anxious, pale and sick, and classically leans forwards drool-
ing wit h an open mout h.
4 Keep the child calm and do not perform any examination or procedure that
might cause distress to the child. Allow the child to be nursed on the parent’s
lap, sitting upright wit h an ox ygen mask held near its face.
(i) Never place an instrument in the child’s mouth to examine the
pharynx.
5 Only perform a lateral neck X-ray, looking for the classic thumbprint sign of
a thickened epiglottis, when the diagnosis is uncertain. A senior doctor must
escort the child with the parent.MANAGEMENT1 Call the senior ED doctor, paediatric, anaesthetic and ENT teams urgently,
and warn ICU.
2 Stay with the child until help arrives.
3 Be prepared to attempt intubation with a small endotracheal tube and an
introducer if sudden respiratory arrest occurs, or
(i) Insert a large-bore i.v. cannula through the cricothyroid
membrane if this fails, as an emergency airway (see p. 470).
4 Commence antibiotics i.v. with ceftriaxone 50–100 mg/kg/day (max 2 g).Inhaled foreign body
DIAGNOSIS
1 This is most common in toddlers aged 1–3 years, frequently involving food
products and usually affects the right main bronchus.
2 Children may present with upper airway obstruction, inspiratory stridor or
with wheeze and a persistent cough following a sudden choking episode.
(i) However, a history of foreign body inhalation is not always
present, or observed.
3 All symptoms may disappear if the object passes into the lower airways.
Later, wheeze, infection or obstructive emphysema supervene, causing local-
ized rhonchi, crepitations and breathlessness.