Approach/management of patient with Stridor

Stridor is an abnormal, high-pitched sound produced by turbulent airflow through a partially obstructed airway. Stridor is a dangerous finding and may indicate imminent airway obstruction. It can be inspiratory, expiratory or biphasic.

Clinical presentation

• Hypoxia

• Respiratory distress

• Altered mental status

• Inability to speak

• Inability to swallow

Differential diagnoses

Infectious causes

• Croup

• Epiglottitis

• Peri-tonsillar abcess

• Retropharyngeal abcess

Non-infectious causes

• Foreign body obstruction

• Burns

• Trauma

• Anaphylaxis

• Malignancy

• Laryngotracheomalacia

• Stenosis

Investigations

• Blood gases analysis

• Lateral neck X ray (for foreign body, masses or soft tissue swelling)

• CXR (foreign body, evidence of aspiration)

• CT-scan

• Blood Sugar

• Lactate

• Electrolyte analysis

• Serum creatinine and urea

Non-pharmacological treatment

Keep the patient calm by allowing the patient to assume their most comfortable position. Give oxygen if there are signs of increased work of breathing.

Pharmacological treatment

A: adrenaline (nebulization) 0.5mls/kg

AND

A: prednisolone (PO) 1–2mg/kg stat

OR

D: dexamethasone (PO) 0.6mg/kg stat

Referral

All patients with stridor whom the cause has not yet been established must be referred to higher health facilities.

1.2 Approach to upper gastrointestinal bleeding

Upper GI bleeding is any GI bleeding originating proximal to the ligament of Treitz.

Clinical presentation

Hematemesis and coffee-ground emesis suggest a UGI source. On physical examination, vital signs may reveal obvious hypotension and tachycardia. Cool, clammy skin is an obvious sign of shock.

Abdominal examination may disclose tenderness, masses, ascites, or organomegaly. Perform rectal examination to detect the presence of blood and its appearance, whether bright red, maroon, or melanotic.

Other findings include the presence of spider angiomas, palmar erythema, jaundice, and gynecomastia which may suggest liver disease, while petechiae and purpura may suggest an underlying coagulopathy.

Differential diagnosis

• Peptic ulcer disease

• Upper GI malignancy

• Oesophageal or gastric varices

• Esophagitis

• Mallory-Weiss tear

• Boerhaave syndrome

• Arteriovenous malformation

Investigations

• ABO Grouping and cross-matching

• Complete Blood Count

• Hemoglobin Level

• Blood Urea Nitrogen and Creatinine

• Electrolytes (Sodium, Potassium, Calcium, Chloride)

• PT, PTT, INR

• Liver Function Tests

• Lactate levels

• Obtain an ECG in patients with underlying coronary artery disease

• Bedside Ultrasound

Non-pharmacological treatment

Maintain ABCs, give oxygen if needed.

Pharmacological treatment

Blood transfusion

Give blood if severe pallor, ongoing bleeding, Hb < 5g/dl and Hb < 7g/dl (with active bleeding).

• Adults: 2 units within 1 hour

• Paediatric: 20ml/kg within 1 hour (whole blood) or 10ml/kg (pRBC)

If ongoing indication for blood, start transfusion in the following ratio:

• 1 unit pRBCs (20ml/kg in Paediatric)

• 1 unit FFP (20mls/kg in Paediatric)

• 1 unit PLT (20ml/kg in Paediatric)

Fluid resuscitation

Give:

A: 0.9% sodium chloride (IV)

OR

A: compound sodium lactate (IV)

• Adult: 2000mls

• Paediatrics: 20ml/kg

Proton pump inhibitor therapy

AND

C: pantoprazole (IV)

• Adult: 80mg stat, then infusion 8mg/hour for 3 days

• Paediatrics: 1mg/kg stat (max 80mg), then infusion 1mg/kg/hour for 3 days

OR

S: esomeprazole (IV) 40mg 24 hourly for 3 days

Suspected variceal bleeding

For patients with suspected variceal bleeding give:

S: octreotide (IV)

• Adult: 50mg slow bolus, then infusion 50mcg/hour for 5 days

• Paediatrics: 1mcg/kg/hour (maximum 50mcg/hour) for 5 days

Cirrhosis-associated bleeding

If features suggestive of cirrhosis; give:

C: ciprofloxacin (IV) 500mg 12 hourly for 7 days

OR

B: ceftriaxone (IV) 2g 24 hourly for 7 days

Definitive care

Early Endoscopy and Intensive care unit admission (Refer Gastrointestinal disease chapter).