434 Emergency Medicine
and T4, respectively. Once they pass the pylorus, most foreign bodies pass
through the remainder of the GI tract. Objects that are larger than 2 cm×5 cm,
sharp objects (needles, tacks), or disc batteries should be considered for
removal.
Although foreign body aspiration (a)is a possibility, the position of the
coin in the radiograph and the absence of respiratory symptoms make this
diagnosis unlikely. If there is a suspicion for an aspirated foreign body, the
patient should undergo bronchoscopy. Bronchospasm (b)occurs as a reac-
tion to aspirated foreign bodies and should always be considered in patients
presenting with cough or respiratory symptoms. Although seen infrequently
in children since the advent of the H Influenzaevaccine, patients with epiglot-
titis(d)classically present with drooling and assume a “tripod position” to
assist their breathing and will often show evidence of respiratory distress.
Allergic reaction (e)is unlikely given the absence of dermatologic or respira-
tory symptoms.
393.The answer is e.(Fleischer and Ludwig, pp 803-805.)This is a case of
laryngotracheitisorcroup.It is the most common cause of stridor and
upper respiratory obstruction in children 6 months to 3 years old. It usually
begins with constitutional symptoms and subsequently patients develop
the characteristic “seal-like” cough. The etiology is most commonly the
parainfluenza virus.Diagnosis is usually clinical. Treatment includes racemic
epinephrine, particularly when stridor is present. Following administration of
racemic epinephrine, patients should be observed for 3 to 4 hours to monitor
for a rebound effect after the epinephrine wears off. Steroidsare administered
as well to reduce the swelling of the larynx.Dexamethasone is the com-
monly administered steroid. Some home-based treatments, such as taking a
child outdoors to breath cool air (as croup presents most typically in the win-
ter) or into the bathroom to breath the steam produced when running hot
water in the shower both seem to aid in symptomatic relief.
Radiographs of the chest (a)to evaluate for pneumonia and the soft
tissues of the neck (c) are not indicated in patients presenting with classic
findings for croup. A CBC and blood culture (b)are of no utility in a
patient with this classic viral illness. Antibiotics (d)are not effective in
patients with a viral illness.
394.The answer is d.(Fleischer and Ludwig, pp 734-739.)The ECG
shows a narrow complex tachycardia at 300 beats per minutewith no
variability and absent P waves. This is diagnostic of supraventricular