9 y/o M Diff Breathing and Chest Pain

LACoGurneyjockey

LACoGurneyjockey

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Not sure where to post this, so please move it as needed.
BLS crew working stand-by at an event, you are called for a 9 y/o male "hyperventilating and can't catch his breath". You arrive to find the patient in tripod position w/ accessory muscle use, audible wheezing as you walk up, obvious respiratory distress. Pt denies pain, only c/o difficulty breathing.
Pt states he began having difficulty breathing 5 minutes ago while playing soccer in 95 degree weather, states he had some water to drink but cannot show me a specific water bottle.
Skin is warm/flush/diaphoretic, respirations rapid w/ low tidal volume about 36/min, pulse is 140 S/R, SpO2 94%, wheezing bilat. Per Pt mother, no pmHx, NKDA, no meds. You give Pt O2 @ 2lpm by cannula and instruct slow deep breaths, within a minute Pt states it is becoming easier to breath, respirations down to 20/min w/ NTV, SpO2 98%, pulse still 140, wheezing no longer audible.
At this point, Pt mother arrives with a bottle of water that Pt drinks quickly, and begins drinking a second bottle just as fast. Finishes both 16oz. bottles within 2min. At this time Pt has no accessory muscle use, can sit or stand comfortably, RR 18/min NTV, pulse still 140, states no longer having diff breathing.
Remove the cannula and Pt starts walking w/ mother to car and you accompany them to monitor. 30 seconds later Pt states "my heart hurts".
Begins c/o 9:10 chest pain, sudden onset, localizes Lt Mid Clavicular 3rd intercostal, non-radiating. Take a BP to find it at 200/110.
Request ALS and give O2 at 15lpm by NRB. Reassess, BP 210/130, pulse 110 S/R, Respirations 30/min, wheezing returns, low tidal volume, SpO2 98% on 15lpm.
ALS arrives, hooks up a 12 lead, and transports code 3 to nearest ER 2 miles away.
Anything to do differently, anything I missed, any possible causes?
I doubt a 9 y/o is having an MI, initially presented like heat exhaustion, maybe undiagnosed asthma, afterwards I started thinking about hyponatremia or hypocalemia from the rapid fluid consumption, any other ideas?
 
Bizarre. I would have first guessed mild exercise induced asthma, but after the second set of symptoms unsure.
 
Just curious why did you start him on 2 LPM via NC when the c/c was SOB, but then when it became CP you blasted him with 15 via NRB? Did his spO2 decrease? Work of breathing change? S/s that required that much O2?
 
mike1390 said:
Just curious why did you start him on 2 LPM via NC when the c/c was SOB, but then when it became CP you blasted him with 15 via NRB? Did his spO2 decrease? Work of breathing change? S/s that required that much O2?
Click to expand...

That's how he/she was trained. I know, I know, but that's what it comes down to. Right out of the curriculum. :sad:
 
rmabrey said:
Same boat
Click to expand...

I'd like to add that I'd sure like to know what the 12-lead showed.

With that said, I actually know a guy who's child went into a hypertensive crisis similar to this during a baseball game. 9 years old similar symptoms, BP >200/100, etc. Doctors hadn't pinned a diagnosis after a 3 months.
 
Why does the second set of symptoms necessarily rule out asthma? Can't asthma cause chest pain? The Hypertension is a bit odd.

A little bit of researched revealed Pulmonary Hypertension as possibly fitting the bill...but honestly, for some really strange reason something in my mind is telling me to suspect PE. Sudden onset dyspnea in an otherwise healthy young person with no history of asthma is a red flag to add PE to my differential list at least. Then again, I could be way off base here.
 
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Based on what I've read here, this doesn't seem to be Exercise Induced Asthma. I've never seen it be a sudden-onset, post workout complaint. It usually starts early in the workout and tends to go away after a good warmup.

PE basically tops my list of what's wrong. Sudden onset of difficulty breathing, get him comfy and then he starts walking and immediately has sudden onset of point-specific non-radiating chest pain. He gulps down 32 ounces of water, this tells me that he's pretty dry. He's been working out in 95 degree heat. It's possible that he's developing some type of coagulopathy and is starting to throw clots. Why is he hypertensive? Well, I would be too, if I was 9 and had really painful chest pain, can't breathe, and don't know what's going on.

Is this really his problem? I have no idea, but I can't think of much else that would cause such sudden onset of a problem.
 
mike1390 said:
Just curious why did you start him on 2 LPM via NC when the c/c was SOB, but then when it became CP you blasted him with 15 via NRB? Did his spO2 decrease? Work of breathing change? S/s that required that much O2?
Click to expand...

Started him on 2lpm because his SpO2 was only down to 94% and it effectively reduced the SOB for the time being. Upped it to 15lpm with CP because that's my protocol and we're BLS, although he did start wheezing again with the CP. Unfortunately, with chest pain O2 is not at my discretion, even if he's satting at 99%.

Regarding the possible PE, is that consistent with severe wheezing?
 
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Ok I guess just the way I read it made it sound like a child in pretty severe respiratory distress (tripoding, accessory muscle use, audible wheezing) I just found it peculiar that you would start at 2 LMP on a clear sob call. Just to play devils advocate... You mentioned that the reason for the initial NC was due to a reading of 98% if you didn't have an SpO2 would you have treated differently and if the reading was 100% would you have withheld oxygen?
 
Maybe I'm not painting a clear enough picture, but when I first arrived it looked like heat exhaustion, maybe exercise induced asthma, but as soon as I sat him down, started the cannula, and coached him on slow deep breaths his wheezing subsided and he was sitting comfortably without distress. I only gave O2 to calm him down, not to treat such mild hypoxia.
 
Here are some links about wheezing and PE

Link 1 9.1% presented with wheezing
Link 2

There can also be ECG changes too. Here is a Link to a review of what can present, but the short of it, is that there will be t-wave inversion is 2-3 precordial leads and a RBBB. I doubt this would be going through many medic's head if they say it, I know I had to review it. Putting myself in their place, seeing the hypertension, tachycardia, and a RBBB on a kid along with his other symptoms would kick my rear into gear.

Now with that said, and knowing were speculating at best, I would also expect to see lowered spO2, and if perfusion and air trapping was bad enough, mottling of the skin (also called mosaic?). These symptoms should also progressively get worse over time.

Question for the OP: Are you certain those wheezes were in all fields? Did you personally listen to them with a stethoscope? Could they have been stronger sounding in one part of the lungs that other parts, or...did you hear audible wheezing when you walked up and left it at that (happens all the time)?


See, we're learning!
 
Interesting. I as well would have loved to see the 12 lead. Electrolyte abnormality is definitely on my list of ddx, however it is unlikely to be caused by the sudden water consumption, doesn't sound like enough time or water to absorb and cause it. Perhaps an underlying one? PE is something to think about but with audible wheezes that doesn't sound right either. Perhaps asthma or hyperventilation, with underlying dehydration? Was he coughing at all? Sounds like maybe a muscle strain after that much work of breathing, which if he had that much of a thirst reflex would also point to electrolyte abnormalities, possibly adding to the strain if it was hyponatremia or hypocalcemia. Either way, he's getting a 200cc fluid challenge and bloods drawn. I'd love to see the ekg and get a bit more of a description of thewheezes to make sure that is actually what they were - not turbulant upper airway noises.
 
morbusstrangularis said:
Interesting. I as well would have loved to see the 12 lead. Electrolyte abnormality is definitely on my list of ddx, however it is unlikely to be caused by the sudden water consumption, doesn't sound like enough time or water to absorb and cause it. Perhaps an underlying one? PE is something to think about but with audible wheezes that doesn't sound right either. Perhaps asthma or hyperventilation, with underlying dehydration? Was he coughing at all? Sounds like maybe a muscle strain after that much work of breathing, which if he had that much of a thirst reflex would also point to electrolyte abnormalities, possibly adding to the strain if it was hyponatremia or hypocalcemia. Either way, he's getting a 200cc fluid challenge and bloods drawn. I'd love to see the ekg and get a bit more of a description of thewheezes to make sure that is actually what they were - not turbulant upper airway noises.
Click to expand...

I guess 2 big questions that remain that cannot really be verified is:

1. Was the BP really that high? Was it confirmed by arriving providers?
and
2. Was the Pt really having wheezes?
 
Interesting info about wheezing and PE. Wheezing was audible when I first approached and I left it at that, when the CP started I listened with the stethoscope and it was audible bilaterally, but stronger on the Upper Left, where he localized the pain.
Talking with my partner after, he also floated the idea of a muscle strain after accessory mucle use. I wish I could have seen the ekg but ALS was on scene for maybe 2 minutes all together with <5 minutes transport time.
 
Jambi said:
I guess 2 big questions that remain that cannot really be verified is:

1. Was the BP really that high? Was it confirmed by arriving providers?
and
2. Was the Pt really having wheezes?
Click to expand...

Jambi, Akulahawk, good ones, as for all.

1. I will take your word about wheezes, but I have seen health professionals who cannot tell a wheeze, rales, rhoncus or stridor apart; as long as it is audible without a scope, it's a wheeze. We're talking difficulty exhaling properly, right?
2. Did you watch them closely? Did the mom slip him an inhaler?
3. As above, how was this BP measured? Was it rechecked in a different mode? (e.g., if done by machine was a manual done; if manual, use other arm or use machine). Contributing to that was pulse taken apically or manually? (GOOD noting that it was regular, as irregular pulses or pulses with regular rythmn but irregular strength can fool a machine and some practitioners!).
4. Chewing gum aspiration into left bronchus ruled out, right? (No note of lung sounds re bilaterally).

Sounds like as good a BLS as one can do, and good recounting.
About that O2 for reassurance thing.....;)
 
Jambi said:
I'd like to add that I'd sure like to know what the 12-lead showed.

With that said, I actually know a guy who's child went into a hypertensive crisis similar to this during a baseball game. 9 years old similar symptoms, BP >200/100, etc. Doctors hadn't pinned a diagnosis after a 3 months.
Click to expand...

Wow, a subject worthy of its own thread if this one doesn't nail it.
 
references for sudden death in young athletes

http://205.214.166.103/administrators_school_officials/Suddendeathinathletes-review-NEJM202003.pdf

http://www.bmj.com/content/337/bmj.a1596?ijkey=YPHmZhYAOhC0O02&keytype=ref
0.jpg

I notice they seemingly ignore trauma.
 
I took the BP manually 4 different times, 3 on left and 1 on right, SBP was 190-210 throughout. Manual pulse was regular 110-140 consistent with the reading on the pulse ox. I won't pretend to have extensive knowledge differentiating wheezing or stridor, and mother stated nothing to eat or drink but I never asked about gum specifically. No inhaler from mom, asked specifically about asthma or family Hx, all negative.
ALS also called it wheezing, never got a chance to see their BP.
 
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Beauty, dude. Excellent, especially the deal of matching palpable pulse to pulse-ox!. The gum thing was a zebra I saw once, only the right bronchus, of course.

Wheeze is auscible high pitched noise on EXhalation; not heard nearly as well on inhalation, if at all. Exhalatory effort increased markedly. You can mimic it by exhaling all your air forcefully, then continue forcing; that last squeaking rasp is a forced end-expiratory wheeze. Do that one sitting down.
:ph34r:

Stridor: trouble INhaling. Can also be troubling on exhalation, but since air isn't getting in, effort and noise are more on inhalation. You can mimic it by constricting your throat as you inhale, as most actors do on training films for "wheezing".
 
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