Pediatric Coughing Spell Could be More than Respiratory Distress

 

 
 
 

Chris Kaiser, NREMT-P | | Friday, March 14, 2014


At 8:48 p.m., Ambulance 34, a BLS volunteer ambulance, is dispatched to a private residence for a “7-year-old female patient unresponsive with breathing problems.” As per the service’s dispatch protocol, Medic 72 is co-dispatched as an automatic ALS assist.

Ambulance 34’s EMTs arrive at the home approximately 12 minutes after dispatch. They enter the residence to find the 7-year-old female awake and alert, in no serious distress.

Her airway, breathing and circulation appear to be intact and her skin is pink, warm and dry. Her mother, who’s with her, appears to be very concerned about her daughter’s condition and describes the events leading to the ambulance call.

“We had just finished putting her to bed when she asked for a drink of water. I gave her one and after she took a drink she began coughing. She coughed really hard for a long time. Then she looked like she couldn’t breathe, turned blue and passed out. She then threw up. It scared me. I don’t know what happened.”

The EMTs evaluate the patient and find her to be acting appropriately. She appears apprehensive but allows an assessment. The small patient is breathing normally with adequate rate and volume. Her lung sounds are slightly coarse, with sonorous wheezes noted in the upper lung fields bilaterally.

Her abdomen is soft and non-tender and she’s moving all of her extremities well. Her vital signs are: blood pressure 104/70, pulse 92, respiratory rate 30, and SpO2 of 99% on room air. Her temperature is slightly elevated at 100.1 degrees F.

Her mother says that over the last week her daughter has been exhibiting a persistent dry cough and has occasionally complained of feeling unwell. She’s also been running occasional mild fevers.

Her coughing spell this evening was the most severe episode her mother has observed, and she asks if it’s possible she “coughed so hard that she passed out.”

The EMTs identify that the patient probably won’t require paramedic care and contact their dispatch center to cancel the responding medic unit. However, during their conversation with dispatch the patient begins to cough. She coughs forcefully and repetitively for more than a minute, during which time she vomits. She becomes pale, slightly cyanotic, and appears to lose consciousness.

At the end of the coughing spell the patient inhales sharply and makes an audible, high-pitched noise. The EMTs ask dispatch to continue the responding paramedic crew.

Prehospital Treatment
After the patient’s second episode of coughing with loss of consciousness, the EMTs and the patient’s mother agree an evaluation by a physician is warranted and ambulance transport is appropriate.

The EMTs secure the patient on their stretcher and begin transport to the agreed-upon intercept point with Medic 72. The transporting EMT places the patient on four liters-per-minute of oxygen by pediatric nasal cannula.

When the paramedics meet with Ambulance 34, they continue the BLS care measures already in place. Additionally, they place the patient on a 4-lead ECG, which shows a sinus rhythm without ectopy. The patient experiences no further episodes during the 32-minute transport time.

Hospital Treatment
At the hospital the patient is evaluated by the emergency physician, who closely queries the mother about the patient’s immunization history. Although the patient has been immunized, she lives in a community where pertussis, also known as “whooping cough” or more colloquially as the “100-day cough,” has been identified in the school system.

The patient is discharged home on oral azithromycin and is scheduled for a follow-up visit with her personal pediatrician.

The EMS crews are determined to all have been adequately vaccinated against pertussis through recent TDaP vaccinations and since they were exposed to the patient for less than an hour, they’re not given prophylactic antibiotics but are advised to seek treatment should they develop symptoms.

Discussion
Pertussis is an extremely contagious communicable disease of the respiratory system caused by the bacteria Bordetella pertussis. It’s a serious disease and can be fatal in very young, very old or immunocompromised patients. It can also be severely debilitating in both adults and adolescents and can lead to complications such as rib fractures and pneumonia. It was prevalent in the United States until the introduction of its vaccine in the 1940s, when the disease became almost unheard of.1

The clinical course of whooping cough progresses through three distinct stages, each with its own set of distinctive symptoms.

The first is the catarrhal stage which is characterized by mild symptoms similar to the common cold. Patients suffer only a mild, occasional cough as well as a runny nose, low-grade fever and sneezing. This lasts approximately one or two weeks and is followed by the paroxysmal stage, characterized by bursts of numerous, rapid coughs thought to be caused by the buildup of thick secretions in the tracheobronchial tree due to paralyzation of cilia caused by the disease process.

Paroxysms of coughing cause the patient to expel a great deal of air out of their lungs because they can last more than a minute. During a paroxysm, patients can display posttussive emesis, cyanosis and even loss of consciousness.

At the end of a paroxysm patients inhale sharply, which is said to make a “whoop” sound as they draw in air. This is the hallmark symptom of the disease and also gives pertussis its common name. However, these symptoms aren’t always present in clinical pertussis cases. In infants, pertussis may present solely as apneic episodes, gagging or gasping, and in older patients the distinctive “whoop” is not always present.

The paroxysmal stage can last between one and six weeks, with paroxysms first building and then waning in number and intensity.

The third and final stage is the convalescent stage, which is characterized by a slow and gradual recovery. The paroxysms lessen in severity and become much less frequent, but can return over a period of several months in response to subsequent respiratory infections or other stimuli such as eating or drinking.1

Pertussis is spread via droplets expelled by patients when they’re coughing or sneezing. It’s an impressively contagious disease that spreads insidiously because it’s most contagious during the catarrhal stage when symptoms of the disease are very mild and/or undetectable.

The infectious period for untreated pertussis is anywhere from 7–21 days after the onset of cough. However, this is reduced to five days post start of antibiotic treatment for clinical cases.

The best prevention for pertussis is widespread vaccination. Because the vaccine is not 100% effective as a preventive, it requires a high percentage of the population being vaccinated in order to effectively control the disease.

In recent years, cases of pertussis have made a dramatic return in all areas of the U.S. due to potential factors such as waning effectiveness of the TDaP vaccine as well as people choosing not to vaccinate children. In fact, pertussis is said to have reached epidemic proportions in Texas and is highly prevalent in some areas of California, but cases have arisen in 49 states.

In 2004, Wisconsin experienced a large outbreak of pertussis that resulted in 5,629 confirmed and probable cases reported to state health agencies.2 In 2009, Texas had 3,358 reported cases and, as of September of 2013, had counted more than 2,000 additional cases.3

Conclusion
Although pertussis isn’t commonly encountered by EMS providers, it’s a growing concern. Paroxysms of coughing that result in severe symptoms such as cyanosis or loss of consciousness mimic a number of conditions that commonly result in ambulance calls.

In infants, apnea is a common reason for activation of the 9-1-1 system. These patients will need to be treated symptomatically for the most severe symptoms of their paroxysms as well as be evaluated by a physician to confirm and treat clinical cases of pertussis. Public health agencies should be notified to help treat outbreaks of the disease and to minimize its spread.

EMS providers should first make sure their TDaP vaccines are updated. Once pertussis is recognized, EMS providers should observe droplet isolation precautions such as wearing a mask and eye protection. The patient may also be masked if they’re able to tolerate it with their respiratory symptoms.

Through recognition of the disease, promoting vaccinations and healthy habits in the community, and by treating the patients who are affected, EMS providers may play a critical role in stemming the growing tide of this serious disease.

References
1. Centers for Disease Control and Prevention. (Dec. 13, 2013.) Pertussis (whooping cough). Retrieved Nov. 14, 2013, from www.cdc.gov/pertussis/.

2. Wisconsin Dept. of Public Health, Immunization Program. (February 2012.) Pertussis (Also known as whooping cough). VPD Surveillance and Control Manual. Retrieved Nov. 14, 2013, from www.dhs.wisconsin.gov/immunization/pdf/pertussis_guidelines.pdf.

3. Murphy, K. (Sept. 5, 2013.) Pertussis reaches epidemic level in Texas. Medscape. Retrieved Nov. 14, 2013, from www.medscape.com/viewarticle/810561.

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Related Topics: Case of the Month, Patient Management, whooping cough, tdap vaccine, respiratory problems, pertussis, pediatrics, paroxism

 
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Chris Kaiser, NREMT-PChris Kaiser, NREMT-P, currently works as a paramedic in northern Illinois and southern Wisconsin. He writes about advancing EMS and is on a personal quest to make EMS the profession it deserves to be.

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