twiter1A mom brings in her 5-year-old daughter to the ED for a persistent cough of over 2-weeks.  She states the cough gets so bad at times that the patient has difficulty breathing.  The patient is nonimmunized based on religious belief.

Diphtheria Pertusis (Whooping Cough) in an Unvaccinated Child

  • Bordetella pertussis is the causative organism.  It is highly contagious and spread by contaminated droplets
  • Infection typically occurs in nonimmunized or partially immunized children and adolescents.  It is also known to occur in adults since the immunization series does not guarantee life-time protection.
  • Clinical presentation is divided into 3 stages
    • Catarrhal (up to 2 weeks) – mild fever, rhinorrhea, conjunctivitis
    • Paroxysmal (2 to 4 weeks) – unremitting paroxysmal coughing followed by a “whoop” (listen here).  May occur 40x per day.  Post-tussive emesis is common.  Listen to a more severe case. Apnea and choling spells are not uncommon.
    • Convalescent (weeks to months) – residual cough
  • Older children commonly misdiagnosed with “chronic bronchitis”
  • Treatment
    • Erythromycin-based antibiotic (azithromycin, clarithromycin)
    • Hospital admission (with isolation) for patients < 1-yr-old or any patient in respiratory distress
    • Monitor for valsalva-induced-bradycardia and hypoxia
  • Highest mortality in children less than 1-year of age (highest in first month of life)

TWITTER notes (This Week In The ER) is an educational resource that presents high-yield, case-based information from actual patient presentations in the ED.


twiter1A 35-year-old woman presents to the resuscitation room with shortness of breath that began earlier in the afternoon.  The patient has a history of asthma.  On exam, she is in obvious respiratory distress with retractions, accessory muscle use, and faint wheezing on auscultation of her thorax.  She rapidly decompensates and has to be endotrachealy intubated.

Acute asthma exacerbation with respiratory faiulure

  • The most common predictors of fatal asthma seem to be a past medical history of intubation/mechanical ventilation and underuse of steroid therapy
  • Findings suggestive of severe asthma
    • dyspnea so severe the patient is only able to speak a few words at a time
    • poor air movement on auscultation of the lungs
    • use of accessory muscles – reflects diaphragmatic fatigue
    • silent chest – indicates that airflow is dramatically reduced and is no longer adequate to cause wheezing
    • diaphoresis
    • cyanosis – late finding, appearing just prior to respiratory arrest
    • altered mental status – may indicate hypercapnia and often reflects impending respiratory failure
  • Treatment of severe asthma
    • beta2-agonists (onset of action < 5 minutes)
    • anticholinergic agents (onset of action up to 30 minutes)
    • corticosteroids (onset is gradual with initial improvement at 3 hours)
    • heliox
    • magnesium sulfate
    • terbutaline/epinephrine – reserved for patients who are too sick to provide an effective respiratory effort
    • mechanical ventilation – high rate of iatrogenic complications (barotrauma)
      • hypoventilate (8-10 breaths per minute – permissive hypercapnia)
      • I to E ratio increased to at least 1:4

TWITTER notes (This Week In The ER) is an educational resource that presents high-yield, case-based information from actual patient presentations in the Detroit Receving ED.