On a late spring day at 0745 HRS, 9-1-1 was contacted because an 8-year-old female was reported not breathing and without a pulse. Upon arrival of the crews, the patient was found in a bathroom of her home and appeared to be pulseless and apneic, with extremely mottled skin. Some attempts at cardiopulmonary resuscitation (CPR) had been commenced by the father, but initial responders felt the efforts were inadequate. The father employed a Heimlich maneuver, followed by an oral finger sweep because the father thought that the patient might have choked on her tongue.
The patient was moved into the bigger space of the kitchen, and CPR was initiated. After chest compressions and use of a bag-valve-mask (BVM), the patient was successfully intubated with a 5.0 mm endotracheal tube and confirmed via standard, local procedures at 0757 HRS. However, the patient remained pulseless, and cardiac monitoring revealed asystole. The patient continued to be cyanotic, with absent capillary refill. An intravenous line (IV) was established.
During the resuscitation, the following history and observations were noted:
The father advised rescuers that the patient had "laryngitis" and bronchitis type cold symptoms for about two weeks. He also told the crew that the patient was fine at 0720 HRS. "She told me she loved me."
Ten minutes later, the patient ran to her dad and complained that she couldn't breathe. The father recommended the patient drink some of his Mountain Dew which she did supposedly improving her condition. Shortly after this, the patient went to the bathroom, and the dad heard a "thud." The father went directly to the patient and found her not breathing and he was unable to locate a pulse.
Crews noted the patient was clothed only in pajama pants, which were positioned around the mid-thigh area. She was not wearing any underwear or a top. Her legs were wet, presumably due to urinary incontinence. During all of the medical care on scene, the father appeared abnormally calm and comfortable even casual. No other bystanders were noted to be at the scene.
After the IV was placed, the patient received epinephrine 1:10000 at a dose of 0.25 mg. The cardiac rhythm eventually demonstrated an idioventricular rhythm (IVR) without pulses pulseless electrical activity (PEA).
Atropine 0.5 mg was then administered, followed by conversion to sinus tachycardia with pulses. End tidal carbon dioxide (ETCO2) increased from less than 10 to 80. Blood pressure was now measurable at 90/50 mmHg, with a femoral pulse of 164 beats per minute. Oxygen saturation was 100% on 15 liters per minute of oxygen flow.
Enroute to the hospital, the vital signs remained stable with the ETCO2 decreased to 34.
Questions to Consider
What concerns would you have as to the possible explanation(s) for the cause of this unfortunate child's circumstances?
What additional information would you like that was not provided above?
How (and to whom) would you address those issues to?
Would you be concerned about the possibility of communicable disease?
Outcome and Discussion
The patient remained in critical condition throughout the emergency department stay. Unfortunately, after admission there was no evidence of significant brain activity. The patient remained in a persistent, vegetative state. A percutaneous gastrostomy (PEG) tube was placed and the child was ultimately discharged to a nursing home. "In some ways, it really would have been better if she had died," one of treating paramedics later remarked.
Clearly, based on the seemingly unusual characteristics of the father's behavior, non-accidental abuse has to be considered. Evidence may or may not be noted on the physical exam of the patient. Findings such as bruising in various stages of healing would be most common. However, in most severe situations, limb deformities representing old or new fractures might be seen. Specific information regarding contusions, or bruises, nor suspicion of fractures was not given.
Often physical signs are not present, or are very subtle. In the hospital setting, the diagnosis of non-accidental trauma is most often made radiographically. EMS can be instrumental in gathering information at the scene about the living conditions, clothing (such as this case), overall apparent health of other children and evidence of suspected non-physical abuse.
In this case, there was concern about the possibility of non-accidental trauma or non-physical abuse. This was discussed with the treating physicians, nurses and the Department of Health and Human Services. The police were also consulted in this circumstance. Caregivers have a duty to notify appropriate authorities when such situations are suspected.
It was determined that there was no evidence of non-accidental trauma, abuse or neglect in this case. Authorities concluded that the father's stoic response to the crisis was a result of his "prior background in the army." He had apparently been confronted with the deaths of others in the line of duty, as well as a number of other emergent situations.
The final diagnosis leading to the devastating outcome in this patient was staphylococcal tracheitis, complicated by severe anoxic encephalopathy. Staphylococcal tracheitis is a relatively uncommon disease with a mortality rate of up to 20%.
As suggested, the pathology involves infection of the trachea with staphylococcal bacteria, most commonly methicillin sensitive S. aureus. However, lately, reports suggest that methicillin resistant staphylococcus aureus (MRSA) may be associated as well.
Other clinical conditions that might be associated with a similar picture include viral croup and other bacterial causes of tracheitis, including epiglottiitis. In the case of staphylococcal tracheitis, the inflammation often leads to the formation of membrane like lesions that line the trachea. However, such tracheal membranes were not noted by the EMS crew at the time of intubation. The obvious immediate concern is rapid progression to acute airway obstruction, as occurred to this unfortunate young girl.
The development of staphylococcal tracheitis may follow a fairly prolonged bout with an upper respiratory infection, caused initially by a virus. Significant bacterial infections, including staphylococcal tracheitis, often afflict the immunocompromised patient (ex. diabetics, patients with cancer or AIDS, infants and the elderly). There is no evidence this child had any of these risk factors.
In summary, staphylococcal tracheitis is a rare, severe bacterial infection of the trachea in the area of the epiglottis and below. It is an unusual cause of tracheal damage and potential obstruction. It is typically not associated with pneumonia and abnormal breath sounds would most commonly be associated with the trachea (i.e. stridor). It is most similar to epiglottitis, and infections of the trachea caused either by viruses (croup) or other bacteria.
Finally, we were not given any information in the history obtained by the EMS crew as to whether the patient developed a high fever or inspiratory stridor. One would typically expect both conditions in this case.
What Can We in EMS Learn from this Case?
- As always, we take care of the ABCs first, assuming the scene is safe.
- When we have secured the ABCs and/or we have additional resources available, we should carefully observe the scene and bystanders in cases that seem suspicious. Observation should be directly proportional to the sense of hair standing up on the back of our necks.
- Although bacterial infections of the airway are rare, appreciate the speed in which they can obstruct the airway especially in children.
- As usual, it is important to treat every patient as if they are pose to an infectious disease exposure hazard. This was certainly very true in this case. After consideration of non-accidental trauma, an acute, infectious airway disease has to be the foremost thought. Therefore, blood, body fluid and respiratory secretion protection must be undertaken.
- Fortunately, in the case of staphylococcal tracheitis, no treatment with antibiotics to providers that may be exposed to the bacteria is necessary. Some infectious exposures do require prophylactic antibiotics for healthcare workers. Since we don't know with any certainty in EMS what the cause may be in critically ill infected patients, protection is key.