MAT # 17595898
6-year-old male with a history of “moderately severe persistent asthma,” treated with Flovent HFA 220 mcg AM/PM, Ventolin HFA 90 mcg q4 hours, and Albuterol 2.5 mg PRN.
April 7, 2025: Presented to a pediatric ER for cough, shortness of breath, and wheezing despite mother-administered albuterol treatments. ER exam documented tachypnea, labored respirations, abdominal muscle use, retractions, and expiratory wheezing. Influenza and COVID tests were negative. Chest x-ray showed mildly prominent interstitial markings, which may represent nonspecific bronchiolitis. Vital signs:
0124: P 120, R 34, BP 108/70, O2 97%
0229: P 120, R 40, O2 92% → post-treatment P 140, R 36, O2 97%
0256: P 108, R 34, O2 96% → post-treatment P 117, R 30, O2 97%
0407: P 99, R 24, O2 96%
0430: P 98, R 24, O2 95%
Medications given: Decadron 16 mg at 0141; DuoNeb 3 mL at 0142, 0229, 0256, and 0407. Follow-up exams documented resolution of wheezing and retractions. Discharged home around 0430.
April 11, 2025: Mother called 911 at 0245 after the child woke coughing, was unable to catch his breath, fainted, and urinated on himself. While awaiting EMS, mother gave one albuterol treatment. During transport, he was placed on 6 L O2 and received Atrovent 0.5 mg and Albuterol 2.5 mg. Vital signs:
0320: P 119, R 35, O2 89%
0326: P 111, R 48, O2 97%
0334: P 115, R 37, O2 91%
He was taken to a different ER.
In the ER, exam documented respiratory distress, retractions, decreased air movement, and wheezing. He was placed on 7 L O2. Vital signs:
0351: P 108, R 44, O2 89%
0414: P 122, R 26, BP 122/72, O2 92%
0418: P 126, R 26, O2 96%
0426: P 125, R 24, BP 118/75, O2 98%
0458: P 119, R 24, O2 97%
0541: P 104, R 22, BP 97/62, O2 98%
Medications given: 0345 Albuterol 15 mg and Atrovent 1.5 mg; 0350 magnesium sulfate 18.9 mL/hr and Solu-Medrol 50.625 mg; 0458 Albuterol 15 mg. Follow-up exams noted no increased work of breathing, wheezing, or retractions. Although chest x-ray was documented as a possibility, no chest x-ray or labs were performed. Discharged at 0646.
April 12, 2025: EMS was called at 0458 after he again woke coughing, fainted, and urinated on himself. EMS attempted to administer an albuterol treatment, but he became unresponsive. Epinephrine was given, but he remained in asystole. He died shortly after arrival at the ER.
Autopsy: Cause of death listed as acute bronchial edema and acute inflammation with acute interstitial inflammatory infiltrate consistent with early pneumonitis.
Looking for causation analysis on the most likely mechanism of death and whether the clinical course suggests an asthma-driven fatal event, an infectious pneumonitis-driven respiratory failure, or a combined process, and whether continued observation/inpatient management after the April 11 ED presentation would more likely than not have prevented or delayed the death.
Files:
Q: We’re any arterial or capillary blood gases obtained?
A: No, never obtained at any admission
Do you believe there might have been medical error?
Patient had loss of consciousness at home on April 11th which is red flag for severity of event. Based upon information given this patient should have been hospitalized. Was an arterial or capillary blood gas obtained?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Patient seemed to be in status at Asthmaticus.
What makes you a good expert for this case?
Extensive prior experience treating hospitalized including those admitted to PICU.
How often do you encounter cases similar to this one in your practice?
Spent over 30 years caring for patients admitted to hospital with respiratory issues, only stepping down to seeing patients in office only over past year at age 66
Do you believe there might have been medical error?
Patient improved with treatment and was released from ER properly
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Same response as above. Patient improved with treatment and was released from the er properly
What makes you a good expert for this case?
I’m a board certified pediatric pulmonologist with 26 years of experience
How often do you encounter cases similar to this one in your practice?
Frequently , I see similar cases all the time
Want to open a case or submit response?
Comments are accepted only from Pediatric Pulmonology experts.