LA Peds Ready is a collaborative effort to ensure that every emergency department in Los Angeles County is prepared to provide high-quality, life-saving care for children. High levels of Pediatric Readiness are associated with:

• Up to 76% reduction in mortality for critically ill children
• Up to 60% reduction in mortality for injured children
• An estimated 2,143 children’s lives saved each year nationwide
• ED costs ranging from $4 to $48 per child

Welcome back to Part 2 of our two-part podcast series on special pathogens. In Part 1, we laid the groundwork for recognizing and preparing for special pathogens in the emergency department, and now we’re putting those principles into practice. In this episode, we’ll work through a case alongside our subject matter experts involving a critically ill 6-month-old presenting with severe respiratory distress. As the case unfolds, we’ll discuss initial stabilization, protecting the healthcare team, key exposure questions that can change your differential, and the recognition and management of suspected H5N1 avian influenza, including PPE, respiratory support, diagnostic testing, antiviral treatment, post-exposure prophylaxis, and coordination with public health.

Show notes by Samara Fattal

The Case:

A 6 m/o female, very lethargic, currently in respiratory distress, is en route to the ED via EMS.

They report the following vitals: HR 70, RR 60, O2 80%

You have time to assemble:

• Resuscitation team:
  • At least one bedside nurse, physician and available trainees, respiratory therapist
  • Hold a brief huddle as patient if possible.
• Necessary PPE
  • Respiratory distress is commonly related to infectious diseases.
  • At a minimum, the team should wear a common surgical mask
    • If indicated, fit tested N95 for highest protection
    • An isolation gown
    • Gloves
    • Eye protection.

As the child arrives in the ED, you notice significant respiratory distress, head bobbing, tracheal tugging, abdominal breathing, crackles upon lung exam, O2 is at 95% with NRB on 10 L.

• How do you maintain a safe environment for the team while stabilizing the patient?
  • Focus on ABCs (Airway, Breathing, Circulation).
  • Temporize hypoxemia with supplemental oxygen
  • Prepare for further treatment if needed.
  • Assess neurological status (lethargy/pallor can indicate shock or hypoglycemia).
  • Place IV and obtain labs (electrolytes, glucose, CBG).

Patient continues to have tracheal tugging and is awake but looks lethargic, RR 50s, Cap Refill 4 secs; Glucose 70, Temp 39

• What next:
  • Support circulation and fluid volume with fluid bolus.
  • antipyretic
  • Heated high flow nasal cannula (have all medications/intubation equipment ready)
• For invasive positive pressure in a 6 m/o:
  • Check capillary refill, hemodynamic stability, and mental status to determine if patient needs peri-arrest support
  • For intubation:
    • Miller 1 blade, cuffed endotracheal tubes (3.5 and 4.0) and stylet ready.
    • RSI medications: fentanyl (1 microgram/kg), (midazolam 0.1 mg/kg), rocuronium 0.6 – 1.2 mg/kg
    • Fluid – can give saline flush for infant
    • 1/10th code dose epinephrine = push-dose epi or epi “spritzer”

• What to ask the family to help get to a diagnosis:
  • Think about the type of infectious disease this could be: covid or flu vs more novel respiratory pathogen (MERS, Avian influenza).
  • Have they traveled anywhere outside of the US?
    • If yes, think more MERS
    • If no start thinking about high risk activities:
      • Have they been around anyone sick?
      • Have they been around any animals that are sick or have died unexpectedly?

In this case, the family has not traveled and the child was previously healthy. Nobody else is sick, but the family has a number of chickens, a few of which have passed away over the past week.

• Suspected H5N1 clues:
  • Contact with someone who has a confirmed H5N1 case in last 10 days
  • Contact with sick or dead animals
  • Consumption of raw milk (drinking unpasteurized milk from infected cattle)
  • Parents visited live animal market, work in slaughter house, etc
  • This patients community is facing an outbreak of avian flu
  • Conjunctivitis cases in the home
• In a highly suspicious case, which team members should take prophylaxis?
  • Check most recent public health guidelines
  • For H5N1, a viral respiratory panel PCR (unless a false negative) will be positive for influenza A, which can lead to an incorrect reassurance that the patient simply has influenza A.
    • Hospitals should do subtype testing or samples should be sent to public health to reveal H5N1 rather than seasonal influenza.
  • Once a patient is tested, if positive all staff would be considered high risk and need chemo prophylaxis administered within 48 hours.
    • Oseltamivir is easily accessible post-exposure prophylaxis
      • 2 times per day typically for up to 5 days

How does H5N1 act differently?

• Causes bird/avian flu: contagious disease circulating in wild birds and poultry but mixes with other flus in intermediate mammals and infect humans.
  • Symptoms are indistinguishable from other respiratory illnesses or seasonal flu.
  • Exposures and risk factors (e.g. conjunctivitis).

Once confirmed  H5N1, what medications are appropriate for patient treatment?

• Typically oseltamivir is appropriate and available.
  • Pt is not taking oral intakes: Oseltamivir given through feeding tube
• Invasive or noninvasive positive pressure ventilation, hydration/electrolyte management.
• If a patient develops shock, then treat shock with fluid management and antibiotics until negative cultures (inotropes or vasopressors as needed).
• PICU care for respiratory failure and organ dysfunction is key.

Key tips:

• Consider the patient simultaneously with the safety of the hospital and healthcare team.
• With respiratory distress or failure patients, consider using an N95 or CAPR/PAPR rather than simply using a surgical mask.
  • H5N1 is not the same as Ebola in that exposure and self monitoring with early intervention, in healthy adults, usually has a good outcome.
• Stick to ABCs, treat shock and respiratory failure, work closely with public health for diagnosis and patient destination.
• Contact tracing: Have EMS rig number to be able to contact EMS and keep track of team who interacted with patient early on