Pediatric Shortness of Breath Case

Case Presentation:
 
3 year old female presents to a district hospital in Dar es Salaam for concern over breathing fast and decreased energy. Approximately 2 weeks ago the child was pushed into a hole and then development progressive dyspnea. Child continued to worsen with no intervention and treatments over a 2 week period. The patient has no significant past medical or surgical history and no known allergies.
 
Physical Exam:
 
Vital Signs:
HR 150                  BP 92/60              RR 40     Temp 37.6 C PO                O2 Sats 97-100%
Awake and alert, noted to be leaning to the left
Tachypneic
Swelling over L chest ant L scapula
Lung sounds absent on L side of chest
Trachea is deviated to the right
Apical impulse is shift to the right
 
Differential Diagnosis:
Hemothorax
Pnemothorax
Pneumonia
Empyema
Pleural Effusion
Bronchial obstruction/atelectasis
 
Tests:
Chest XR
IVF
What if you had no immediate access to radiological imaging? Remember the use of bedside ultrasound!

Concern for Empyema
 
Next Steps:
Chest tube placement
Antibiotics
Sedation
Local Anesthesia
Sterile technique

Reassessment:
Child’s tachypnea has improved after chest tube placement and nearly 1 liter of pus was drained from the chest.
                          
Case Pearls: 
Utilization of bedside ultrasound
Remember your ultrasound skills and abilities when you are working in a setting with limited resources. If you cannot obtain immediate chest x-ray, you can use your bedside ultrasound to evaluate the chest to diagnosis pneumothorax, hemothroax, empyema, pneumonia, and much more.
See tutorial on thoracic ultrasound or review article on emergency ultrasound of the chest.

Empyema
Empyema is inflammatory fluid and debris within the intrapleural space, usually results from an untreated bacterial pneumonia. However, an empyema can also be caused by thoracic trauma (like our case). Other causes include extension of mediastinal or abdominal infection or iatrogenic causes (chest tube placement or surgery).

Chest tube placement
Before performing any procedure always consider what type of analgesia and sedation the patient will need. Consider the patient’s vital signs/stability and the urgency of procedure when selecting sedation plan. To review chest tube placement watch the following videos.
 
 
Thanks Dr. Mike Runyon for the case submission.