Hello everyone, I'm Dr. Lee.
I saw a news yesterday:
1. Things go through
Two days before going to the People's Hospital, the girl was already suffering from laryngitis and had anti-inflammatory injections and nebulization treatment with the local clinic. Because of the epidemic situation, the clinic could not receive treatment, so the family brought the girl to the people's hospital.
There are detailed information about the treatment process on the Internet: it is reported that the girl came to the hospital at about 2:20 p.m. on the same day, and was first received by a pediatrician, and the diagnosis was laryngitis, because it was not under the jurisdiction of the pediatric department, so the doctor told them to go to the five senses department next door.
The family took the girl to the five senses department, still diagnosed with laryngitis, but the doctor did not give a reply at the first time, asking the child and his family to wait. After that, the hospital informed the patient's family that they needed to take the patient for nucleic acid testing.
The nucleic acid results came out in about two hours, but the child was already showing significant symptoms of discomfort. After the nucleic acid was done, the family took the girl back to the five senses department, and the doctor told the family to take the child to the transition ward on the third floor to wait for the nucleic acid results.
The transition ward is on the first floor and the five senses section is on the fourth floor. The doctor inadvertently said the wrong floor and asked the family to run two more times. Finally, the family took the child to the transition ward on the first floor.
After coming to the transition ward, the family saw that the child was getting more and more uncomfortable and wanted to get an injection to alleviate it, but the hospital stipulated that the transition ward could only give injections to adults, and the children had to go to the fourth floor for injections.
So the family went to the fourth floor again, and the doctor once again asked them to return to the first floor on the grounds that the nucleic acid results had not yet come out. Back on the first floor, the family again asked the nurse to give the child an injection, but the nurse refused on the grounds that she did not know how to use the medicine.
The family went to the fourth floor again, and this time the doctor finally agreed to give the child an injection, but somehow called another female doctor to replace him.
The female doctor still did not treat the child directly on the fourth floor, but asked the family to return to the first floor, saying that she had passed the voice with the nurse on the first floor and allowed the child to drip on the first floor.
At the same time, the female doctor also stressed that when the drip is halfway through, the child should be taken to the fourth floor again to check the condition to determine whether the child belongs to pediatrics or five senses.
The child finally got a little drip, but he developed a fever. The doctor asked them to go to the fever clinic, and the family asked the child to finish the drip first, but the doctor refused.
In desperation, the family could only bring the child to the fever clinic. On the way to the fever clinic, another nurse in charge of the transition ward went through the process again, re-took the temperature, and finally arrived at the fever clinic, which turned out to be the same place where they had been tested for nucleic acid.
After some communication, the family signed an agreement, and the doctor agreed to let the child return to the transition ward to drip. Before and after, the family delayed for fifteen minutes between the isolation ward and the fever clinic alone, and the child's condition became more and more serious.
At 4:40 p.m., the child was dying, received first aid immediately, and ten minutes later, the child lost his vital signs.
The hospital said that after watching the surveillance video of the child's diagnosis and treatment, it believes that the entire admission process is indeed too long. Whether or not it is because the fatality rate of "laryngitis" is not high, so treatment is not arranged in time, because the delay caused the death of a baby, the hospital has an unshirkable responsibility. In the end, the two sides reached a settlement.
Even if reconciled, it is still a tragedy.
Let's try to analyze a few issues that you can discuss together.
2. What disease does the child die from?
Obviously, the child went to the hospital because of acute laryngitis, and the onset of the disease was 2 days, but he died because of the delay in the last 2 hours of the hospital, which is a pity.
This is a death list, and the information on the table clearly states that the direct cause of death is "respiratory, cardiac arrest", and the cause of respiratory cardiac arrest is "acute laryngitis".
3. What is acute laryngitis?
Acute laryngitis is divided into people and children, if it is an adult's acute laryngitis, it is generally no major problem, but if it is a child's acute laryngitis, it is an emergency, and it may be fatal if it is not treated in time or improperly.
Adult acute laryngitis occurs mainly secondary to colds (or infections), such as the beginning is nasal cavity, oropharynx discomfort, there is runny nose, sneezing, sore throat, etc., and then the infection can cause laryngeal inflammation, in addition to excessive use of the larynx can also lead to acute laryngitis, such as singing, talking for too long, everyone must have to go to KTV singing and then the next day can not speak, that is acute laryngitis.
The symptoms of acute laryngitis in adults are hoarseness, cough, sputum cough, sore throat, but generally sore throat will not be very serious, nor will it affect eating, and rest for a few days can basically recover. If it is serious, the key drugs in the treatment are antibiotics & hormones, antibiotics to deal with infections, hormones to deal with inflammation, two together nebulization inhalation effect is good, the disease is very serious can be used intravenously. However, adult acute laryngitis is generally not very serious, and it is rare to hear that adult acute laryngitis can lead to death.
Pediatric acute laryngitis is very different.
Although the names are acute laryngitis, the groups that occur are different, so the nature is different.
Acute laryngitis in children tends to occur in children aged 6 months to 3 years, although the older ones can also occur at 4 to 5 years old. The reason why the symptoms of acute laryngitis in children are different from those of adults is that the submucosal tissue of the larynx in children is relatively loose, and it is easy to swell when inflammation occurs (which is very important and very fatal), plus the laryngeal cavity and glottis of children are small, so children are prone to laryngeal obstruction and cause breathing difficulties.
Doctors in pediatrics, emergency departments, and five senses should know that pediatric acute laryngitis is an emergency and must be treated appropriately and in a timely manner, which is not the same as the treatment attitude of adult acute laryngitis.
In addition, children's cough ability is not strong, the lower respiratory tract and laryngeal secretions are not easy to cough out, so the acute laryngitis in children is more serious than that of adults, if the diagnosis and treatment is not timely, it will really endanger life. It is as if in this case, the child is in the hospital for two hours, and finally has laryngeal edema, blocking the respiratory tract, causing respiratory arrest, and finally dying of ineffective rescue.
4. How to identify acute laryngitis in children?
The causes of acute laryngitis in children are somewhat similar to those in adults, with most secondary to upper respiratory tract infections, such as the common cold (or other respiratory diseases). The child is cold at first, but the cough is getting worse and worse, the voice is hoarse, the cough sound is like a dog barking, just like the puppy barking, the typical cough like "empty, empty", which is different from ordinary cough. Because the child had throat edema at that time, the glottis became smaller, and the air flow in and out of the respiratory tract was blocked, so the coughing sound was different, and the parent should be vigilant.
Secondly, the child will have a stridor sound, and breathing difficulties, breathing difficulties are mainly inspiratory breathing difficulties, you see the child inhalation is very difficult, because the throat becomes smaller, if further progress, will soon be extreme breathing difficulties, three concave signs (supraclavicular fossa, suprasternal fossa, intercostal space will be depressed, because of the force to assist in inhalation), and eventually because of suffocation and lack of oxygen and death.
Parents should pay attention to the fact that when the child's cough is getting worse and worse, especially when it is the same as the sound of the puppy barking, it is likely that the laryngeal edema is swollen, and it is necessary to step up to the hospital, and after going to the hospital, the general experienced doctor will deal with it immediately and pay the fee. If you encounter the doctor's procrastination, or the scene is busy, parents must be bold and find a way to let the doctor deal with the child's situation first. However, in general, the emergency department doctor sees that the child has difficulty breathing, and does not dare to delay carelessly, and will treat it immediately. Unless the child has just been fine and suddenly gets sicker, it is more difficult. But in any case, there is a process of disease change, close observation, understanding the disease, is the key to successful rescue.
As a clinician, you should also understand the disease of acute laryngitis in children, he is not the same as the acute laryngitis of adults, acute laryngitis of adults may not need to be treated to heal itself, but acute laryngitis in children is an emergency, once diagnosed as acute laryngitis in children, effective measures should be taken immediately.
5. How does the doctor deal with it? What should parents do to prepare?
Pediatric acute laryngitis, after going to the hospital, the doctor will definitely give treatment. The most critical is the early use of adequate amounts of antibiotics and glucocorticoids, just as we have just said, many pediatric acute laryngitis may be secondary to bacterial infection (not necessarily, but may be), so early use of antibiotics is key, which is not antibiotic abuse.
More critical is the use of hormones, because the larynx of children may have inflammation oozing edema, minutes may block the glottis, at this time need to quickly reduce inflammation, prevent complete blockage, unblock the respiratory tract, atomization, oral, intramuscular injection, intravenous hormone is very critical, the specific use of which form, depending on the situation at the time, the fastest onset of action is intravenous hormones (such as dexamethasone, methylprednisolone), oral hormones are mainly oral prednisone.
Hormones can quickly act, suppress inflammation and edema, generally as long as the hormones and antibiotics are used in time, they can be alleviated and will not die.
If the child's condition is already quite critical after coming to the emergency room, it is estimated that within a few minutes or even tens of seconds, he will be suffocated due to breathing difficulties, then the doctor cannot wait for the hormone to take effect (even if it is an intravenous hormone, it is impossible to play a great role in tens of seconds), but should take more effective measures to clear the respiratory tract. That is: tracheostomy.
Just as we said, the most feared thing about acute laryngitis in children is fever throat obstruction, once the laryngeal obstruction occurs, the drug may be too late, you must cut the tracheotomy, although the larynx has been highly edema caused by obstruction, but the airway down the larynx is still unobstructed, so we cut a hole in the position of the larynx downward, put a catheter, you can smooth the respiratory tract, save the child's breathing, but also save the child's life.
We replaced the child with a picture of an adult's tracheostomy, but the method of operation is similar.
Everyone will understand after reading it.
Some people may wonder why it is not to take transtracheal intubation, why must the tracheotomy be made? It's traumatic to cut it. Yes, it has to be cut. Because when a child has laryngeal edema, we can't put a tube through the larynx from the mouth, because it has been blocked by edema, and no matter how hard we try, we can't cross this obstacle, but it may aggravate the edema due to the injury. Therefore, when encountering laryngeal obstruction caused by acute laryngitis in children, it is necessary to make a tracheotomy immediately, rather than intubation of the trachea.
Tracheostomy is a bit difficult, not all emergency department doctors or otolaryngologists in all hospitals can be proficient, the key moment can also do cyclothyroidocentesis, this operation is relative to the tracheotomy is simple, the position is similar, are in the trachea under the larynx, but not cut, but take a large needle inserted into it, the needle can temporarily provide a little air, the child will not die immediately, followed by tracheostomy, but the cricothyroid puncture at least won a little time.
In theory, this is how to rescue, how to implement it depends on the level of each doctor in each hospital. To be honest, in a situation where a child is having high breathing difficulties, the parents are very nervous, and the child may have begun to be irritable, it is challenging to do a tracheostomy and a cricothyrocentesis. But there is no way, success or failure is in one fell swoop.
So we still focus on preventing laryngeal obstruction, treating acute laryngitis in children early, and trying not to let it develop to the point where tracheostomy is required. That requires parents to recognize this disease, when the child coughs violently, like a puppy barking, especially when there is already a slight breathing difficulty, it is necessary to step up to go to the hospital, and at the same time, the family can always prepare oral hormones (prednisone acetate tablets, dexamethasone tablets), when the child's breathing difficulties are aggravated, you can take one tablet orally and then rush to the hospital.
I think that parents always have oral hormones, oral hormones to children at key moments is a forced approach, because the disease is ever-changing, the child is not necessarily acute laryngitis (acute epiglottitis is also suitable for hormones), not necessarily suitable for hormones, but compared to the tragedy of losing the child if it is not handled in time, I think parents can give their children hormones in advance, and go to the hospital quickly after eating.
Of course, it is best to be able to contact a doctor in advance, such as a familiar doctor, and use hormones under the guidance of a doctor. Taking ten thousand steps back, in general, taking a tablet of hormones by mouth will not cause any major adverse reactions to children, and there is no need to worry too much.
6. What lessons do we have?
A 4-year-old child, who eventually died of acute laryngitis, was a pity. What is even more heart-wrenching is that there was originally a chance to rescue. Because the child was in the hospital for nearly 2 hours before suddenly progressing to choke. During these two hours, due to the lack of nucleic acid reports and the rotation in several departments, the rescue time was finally delayed.
We couldn't avoid it, the procedure was complicated, and the doctors at the time didn't raise their guard, which was the biggest cause of the child's death. But since we weren't there and didn't understand the situation at the time, there was no way to make more comments so as not to mislead the reader. In any case, the parents and the hospital have reconciled, which is also a little comfort. The compensation should be compensated, the compensation should be in place, and then learn lessons, optimize the process, especially for children with acute laryngitis (but all children with breathing difficulties and barking cough should be vigilant) The treatment process should be more standardized to follow, and when other brother hospitals see such a tragedy, they can also reflect on the situation of their own hospitals, if the child is in the hands of their own hospital, can they get back a life?
That's the most critical.