Respiratory

Epiglottitis with impending airway obstruction — paediatric female

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Pediatric · 8yr · female

Patient Information

Dispatch	You are called to a 8YO female (Chloe Nguyen) at the St John FAP during the Fremantle Festival. Her mother states she has been unwell since this morning and has suddenly become much worse.
Patient	Chloe Nguyen — 8yr (25kg)
Incident History	Mum states Chloe has had a sore throat since this morning. She has rapidly deteriorated in the last 30 minutes — now drooling, unable to swallow, and has developed a high-pitched noisy breathing sound. Mum is extremely distressed.
Emergency Contact	Linh Nguyen (Mother) — 0412 874 931

Initial Rapid Assessment

Response	Voice
Airway	Partially patent but threatened. Audible inspiratory stridor at rest. Patient drooling with inability to swallow secretions. No attempt to examine the throat — risk of complete obstruction.
Breathing	Laboured and distressed. RR elevated with marked inspiratory effort. Intercostal and suprasternal recession visible. SpO2 91% on room air. Patient leaning forward in tripod position with neck extended — do NOT reposition.
Circulation	Radial pulse rapid and weak. Skin pale and diaphoretic. CRT 3 seconds centrally.
Disability	GCS 12 (E3V4M5). Mildly altered — irritable and frightened. Not fully orientated to place. Pupils equal and reactive to light.
Exposure	No rash. No external injuries. No visible trauma. Mum reports no known allergen exposure today. Patient sitting upright in position of comfort — do not force her to lie down.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Severe	36	138	98/62	3s	12	4 4 ++	39.4	–	6
10 mins	89% (O2 NRB 15L)	Severe	40	148	92/58	4s	10	4 4 SL	39.4	–	7

History Taking

Treatment Response

Diagnosis

This patient is suffering from suspected epiglottitis with imminent airway obstruction, presenting with classic features including inspiratory stridor at rest, drooling, dysphagia, high fever, and rapid deterioration. This is a life-threatening paediatric airway emergency.

Facilitator Triggers — if trainees miss a critical step

! (If trainee attempts to examine the throat or uses a tongue depressor — facilitator states: 'Chloe becomes extremely agitated, stridor worsens markedly, and SpO2 drops to 84%. Respiratory arrest is imminent.' This simulates the danger of instrumentation causing laryngospasm.)
! (If trainee attempts to lay Chloe flat or change her position against her will — facilitator states: 'Chloe begins to struggle violently, stridor becomes biphasic, and she becomes more cyanosed. She is maintaining her airway only in the tripod position.')
! (If oxygen is not applied within the first 3 minutes — facilitator states: 'SpO2 drops to 87%, Chloe becomes increasingly drowsy with GCS dropping to 10. Stridor is becoming quieter — a sign of deteriorating air entry, not improvement.')
! (If trainee does not call for urgent ambulance / Priority 1 backup immediately — facilitator states: 'Chloe's breathing effort is visibly increasing. Mum asks: Is she going to be okay? Are you getting help? It has now been 4 minutes and no backup has been requested.')
! (If trainee attempts BVM ventilation prematurely when patient is still conscious and breathing — facilitator notes: 'Gentle BVM ventilation IS effective if Chloe becomes unconscious and apnoeic. However, forcing a mask on a conscious child with a partially patent airway risks further agitation and complete obstruction. Only apply BVM if Chloe becomes unconscious or ceases effective breathing efforts.')
! (If BGL is not checked on any altered GCS paediatric patient — facilitator prompts: 'Chloe's conscious state has dropped. Have you checked her BGL?')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE including gloves and surgical mask.
2. Perform Primary Survey — identify immediately life-threatening airway compromise.
3. DO NOT examine the throat, use tongue depressor, or attempt any instrumentation of the airway — risk of complete laryngospasm and respiratory arrest.
4. DO NOT reposition the patient — allow Chloe to remain seated upright in her self-selected tripod position with neck extended. This is her optimal airway position.
5. Request immediate Priority 1 ambulance backup via State Operations Centre — this is a time-critical paediatric airway emergency. Pre-notify receiving ED of suspected epiglottitis with impending airway obstruction.
6. Keep Chloe as calm and undisturbed as possible — minimise interventions, speak quietly, keep Linh (mother) close as a source of comfort.
7. Apply oxygen therapy — offer blow-by oxygen or apply paediatric non-rebreather mask at 10–15 L/min if tolerated. DO NOT force the mask. Target SpO2 ≥95% in paediatrics.
8. Continuously monitor respiratory rate, SpO2, work of breathing, and conscious state every 5 minutes given time-critical presentation.
9. Perform Vital Sign Survey — GCS, SpO2, RR, HR, BP, temperature, CRT.
10. Check BGL given altered GCS — document result.
11. Prepare BVM equipment in case of respiratory arrest — have suction immediately available. If Chloe loses consciousness and ceases effective breathing, gentle BVM ventilation should be attempted as per Dyspnoea & Respiratory Distress CPG guidance.
12. If respiratory arrest occurs — commence BVM ventilation with gentle low-pressure breaths and manage as per Cardiac Arrest — Paediatric CPG. Assign compressor role, attach AED, and maintain team coordination.
13. Document findings thoroughly on ePCR and prepare IMISTAMBO handover noting: suspected epiglottitis, age and weight (25 kg, 8 years), airway status, drooling, inability to swallow, stridor, SpO2 trend, oxygen administered, GCS trend, and all treatments.
14. Scenario ends on arrival of ambulance and IMISTAMBO handover.
15. 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 · Primary Survey · Glasgow Coma Scale (GCS) · Blood Glucose Monitor · Pulse Oximetry

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Signs/Symptoms	Sudden onset high-pitched inspiratory stridor at rest, drooling, inability to swallow, severe sore throat, high fever, laboured breathing, agitation and irritability.
Allergies	NKDA — confirmed by mother.
Medications	Nil regular medications.
Pertinent History	No prior episodes of croup or airway problems. Fully vaccinated — mother confirms Hib vaccination up to date. No recent overseas travel. No immunosuppression.
Last Oral Intake	Unable to eat or drink since mid-morning due to pain. Last oral intake approximately 6 hours ago.
Events Leading	Family attended the Fremantle Festival this morning. Chloe had been complaining of a sore throat since waking. Mum brought her to the FAP when she noticed Chloe was struggling to breathe and drooling.
Treatment Prior	Mum gave Panadol (paracetamol) this morning for fever — approximately 7 hours ago. No other treatment.

Onset	Sore throat noted this morning; rapid deterioration over last 30 minutes with stridor and drooling now present.
Pain	Severe throat pain — Chloe pointing to throat and crying. Unable to speak in more than one or two words.
Quality	Constant, worsening. Patient increasingly frightened and exhausted.
Radiates	Nil radiation described.
Severity	6/10 on initial assessment — patient too distressed to engage fully.