Presentation at Accident and Emergency

On another shift in paediatric accident and emergency you see some familiar faces – Jack Horner has returned with his parents. When they see you they look away.

The triage nurse has completed his observations:

HR 120/min, RR 32/min, T 37.8 C, SaO₂ 92% in Oxygen,

Weight 11.7 Kg

You take Jack and his parents to a side room and take a history.

Jack is now 19 months old and has come back because of his breathing. He has been had several breathing troubles since he came to the accident and emergency room 8 months ago. This is not surprising as he required ventilation on PICU. After discharge, the breathing troubles cleared up within a few days then and afterwards he was fairly well for a few months.

His GP has wondered if the cause was asthma and started Jack on an inhaler which has most nights. It seems to make his night time cough better.

Since being on the salbutamol he has only had problems when he has also had a cold – when he gets a runny nose, it goes to his chest and he develops a dry cough and has some difficulty breathing.

This episode is a little different to the others – he seemed fairly well until yesterday, and but in the evening seemed to rapidly develop his cough and breathing problems. He also does not seem to have a runny nose at the moment.

You remember that he has an older brother, and find out that he has been doing well. He is 5 years old now and still uses the inhalers for his asthma. 

They ask if the current breathing problem is anything to do with his earlier issues.

You decide to examine him:

Airway patent – talking in single words.

Breathing – mild recession, mild tracheal tug, RR 35/min, reduced air entry on the right side in all zones. SaO₂ 91% in Oxygen

Circulation – HR 120/min, heart sounds and pulses normal.

Neurology – alert and active, appropriately interested and wary of the new location. Playing with toys using both hands and mouthing them, crawling well and walking unsteadily.

What would you like to do now?