Epiglottitis with imminent airway obstruction in a child

Patient Information

Dispatch: You are called to the first aid post at the Perth Royal Show. A parent has carried in an 8-year-old boy (Lachlan Ng) who is sitting bolt upright and appears to be in significant breathing difficulty.
Patient: Lachlan Ng — 8yr (26kg)
Incident History: Mum says Lachlan complained of a sore throat earlier this morning. Over the last hour he has become much worse — he is now drooling, unable to swallow, and making a high-pitched noise when he breathes. No known injury. No bee sting. He has not been eating or drinking.
Emergency Contact: Susan Ng (Mother) — 0412 774 391

Initial Rapid Assessment

Response: Alert
Airway: Partial upper airway obstruction. Audible inspiratory stridor at rest. Drooling present — patient unable to swallow secretions. Do NOT examine the oropharynx or attempt to visualise the throat.
Breathing: Laboured. RR 32/min. Marked intercostal and suprasternal recession. Nasal flaring present. Tripod position — leaning forward with hands on knees, chin extended. Speaking in single words only.
Circulation: Radial pulse rapid and strong. Skin pale. CRT 2s centrally. No external bleeding.
Disability: GCS 14 (E4V4M6). Alert but increasingly anxious and distressed. Orientated to person and place. Not tolerating intervention well — agitation worsens with approach.
Exposure: No rash. No urticaria. No visible trauma. Neck not swollen externally. Temperature 39.2°C tympanic.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Severe	32	138	100/62	2s	14	4 4 ++	39.2	–	7
10 mins	88% (O2 NRB 15L)	Severe	38	152	94/60	3s	12	4 4 +	39.2	–	8

History Taking

Treatment Response

Diagnosis

This patient is suffering from acute epiglottitis with imminent upper airway obstruction, presenting with the classic triad of drooling, dysphagia, and distress, compounded by audible inspiratory stridor at rest, high fever, and rapidly deteriorating respiratory status in a paediatric patient.

Facilitator Triggers — if trainees miss a critical step

! (If trainees attempt to examine the oropharynx with a tongue depressor or torch, or ask Lachlan to open his mouth for direct inspection — facilitator states: Lachlan becomes acutely distressed and agitated. His stridor becomes louder and his SpO2 drops immediately to 84%. The airway is on the brink of complete obstruction. Prompt the trainee: 'What do you want to do now?' This represents complete airway loss.)
! (If trainees attempt to lie Lachlan flat or move him from his tripod position — facilitator states: Lachlan immediately cries out and resists. His stridor worsens markedly and he becomes grey. His SpO2 drops to 86%. Reinforce: the patient has adopted the position that best maintains his airway — do not change it.)
! (If oxygen is not offered gently and non-threateningly within the first 3 minutes — facilitator states: Lachlan's SpO2 drops to 88% and he is now appearing increasingly exhausted. His breathing effort is visibly increasing.)
! (If trainees do not call for emergency ambulance (000) as an immediate priority action — facilitator prompts: 'What backup do you need and how urgently?' This patient requires immediate urgent ambulance via CSP and Advanced Care — EHS cannot manage complete airway obstruction.)
! (If trainees attempt to force any oral medication, oral temperature probe, or oral assessment — facilitator states: Lachlan gags and his stridor worsens acutely. Remind trainees: nothing should be inserted into the mouth or throat of a suspected epiglottitis patient.)
! (If the 10-minute vitals are reached without ambulance being called or oxygen being delivered — facilitator states: Lachlan's GCS drops to 12, his stridor is now louder and higher pitched, and he is beginning to fatigue. He is at risk of complete airway obstruction and respiratory arrest.)

Treatment Objectives

1 Ensure scene and personal safety — don appropriate PPE (gloves, mask).
2 Immediately recognise this as a time-critical paediatric respiratory emergency with suspected epiglottitis.
3 Call 000 immediately for urgent ambulance via CSP with IMISTAMBO handover — this patient requires Advanced Care airway management in hospital.
4 Do NOT examine the oropharynx, do NOT use a tongue depressor, do NOT attempt to visualise the throat — this may precipitate complete airway obstruction.
5 Keep Lachlan calm and minimise all disturbance — speak quietly and calmly, avoid separation from mother, do not force him into any position.
6 Allow Lachlan to remain in his self-adopted tripod/upright position — this is the position that best maintains his airway and must not be altered.
7 Offer blow-by oxygen gently if tolerated — hold oxygen mask near the face without forcing it. If Lachlan will not tolerate a mask, allow mother to hold it loosely near his face. Target SpO2 ≥ 95%. Do not use nasal cannula as this may distress the child.
8 Do NOT administer any oral medications — Lachlan cannot safely swallow and oral administration risks aspiration and airway stimulation.
9 Do NOT administer paracetamol in any form at this time — oral route is contraindicated; no IM or IV route is within EHS scope.
10 Perform and record vital signs every 5 minutes given time-critical status — SpO2, RR, HR, GCS, respiratory distress score.
11 Monitor closely for signs of complete airway obstruction: sudden silence of stridor (ominous sign), decreasing GCS, cyanosis, cessation of respiratory effort.
12 Prepare BVM and suction equipment immediately at bedside — if Lachlan loses consciousness and stops breathing, commence BVM ventilation gently as per Cardiac Arrest / Dyspnoea CPG and call for immediate assistance.
13 If respiratory or cardiac arrest occurs — commence CPR as per Paediatric Cardiac Arrest CPG and continue until Advanced Care arrives. Gentle BVM ventilation may still be possible despite swelling.
14 Do NOT leave Lachlan unattended at any time.
15 Ensure mother remains with patient to provide reassurance — parental presence reduces agitation and airway destabilisation.
16 Scenario ends on arrival of ambulance and IMISTAMBO handover.
17 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Dyspnoea & Respiratory Distress · Choking (Foreign Body Airway Obstruction) · Cardiac Arrest - Paediatric · Bag Valve Mask Ventilation · Oxygen Delivery

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