Rosen & Barkin's 5-Minute Emergency Medicine Consult (247 page)

• Hypertonic saline has been shown to be beneficial in some pediatric studies (1.7–3%).
  
• NaCl 3%: 2–6 mL/kg IV. Infusion 0.1–1 mL/kg/h
  

FOLLOW-UP

• All patients with CT abnormality or altered LOC should be admitted to ICU setting with frequent neurologic assessment.
  
• Patients should have repeated CT exam in 12–24 hr or if clinical deterioration occurs.
  
• Patients at increased risk of deterioration include those with rapid bleeds, associated skull fracture, or lower GCS or neurologic deficits.
  

Admission is necessary for all patients with EDH.

• Blythe BJ, Bazarian JJ. Traumatic alterations in consciousness. Traumatic brain injury.
  Emerg Med Clin North Am
  . 2010;28(3):571–597.
  
• Chesnut RM. Care of central nervous system injuries.
  Surg Clin North Am
  . 2007;87(1):119–156, vii.
  
• Chittiboina P, Cuellar-Saenz H, Notarianni C, et al. Head and spinal cord injury: Diagnosis and management.
  Neurol Clin
  . 2012;30(1):241–276.
  
• Huh JW, Raghupathi R. New concepts in treatment of pediatric traumatic brain injury.
  Anesthesiol Clin
  . 2009:27(2):213–240.
  
• Kubal WS. Updated imaging of traumatic brain injury.
  Radiol Clin North Am
  . 2012;50(1):15–41.
  
• Marion DM. Epidural hematoma. In: Bradley WG, ed.
  Neurology in Clinical Practice
  . 5th ed. Elsevier; 2008:1083–1114.
  

CODES

• 852.40 Extradural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness
  
• 852.41 Extradural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness
  
• 852.46 Extradural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration
  

BASICS

• Rapidly progressive inflammation of the epiglottis and surrounding tissues leading to airway compromise
  
• May be more indolent in adults than pediatrics; rapid progression to total airway occlusion still seen in adults
  
• Although the incidence of pediatric epiglottitis has been decreasing, the incidence in adults is increasing
  
• Inflammation of supraglottic structures:
  
  • Epiglottis:
    
    • Edema is the primary airway concern
      
    • May be primary or secondary from adjacent structures
      
  • Vallecula
    
  • Arytenoids
    
• Incidence is 1–4:100,000 adults per year and rising
  
• More common in men: 3:1
  
• Adult mortality rate is 7% (<1% in children)
  
• Most common in 5th decade of life
  
• Immunocompromised patients may be particularly fulminant, with minimally associated symptoms and unusual pathogens, such as Candida and
  Pseudomonas aeruginosa
  
• Complications:
  
  • Total airway obstruction
    
  • Retropharyngeal abscess
    
  • Acute respiratory distress syndrome
    
  • Pneumonia
    
  • Empyema
    

• Infectious causes:
  
  • Haemophilus influenzae B,
    also type A and nontypeable strains
    
  • Haemophilus parainfluenzae
    
  • Streptococcus pneumoniae
    
  • Staphylococcus aureus
    
  • Group A Streptococcus
    
  • Neisseria meningitis
    
  • Herpes simplex
    
  • Cytomegalovirus
    
  • P. aeruginosa
    
  • Numerous other uncommon agents
    
• Physical agents:
  
  • Chemical and thermal burns
    
  • Toxic or illicit drug inhalation
    
• Trauma, instrumentation
  

DIAGNOSIS

• General:
  
  • Fever
    
• Upper respiratory tract infection symptoms
  
• Prodrome absent in significant number of cases
  
• Head, eyes, ears, nose, throat:
  
  • Dysphagia
    
  • Muffled voice
    
  • Voice change:
    
    • “Hot potato” voice
      
    • Hoarseness
      
  • Foreign body sensation in throat
    
  • Drooling
    
  • Associated tonsillar, peritonsillar, uvular findings
    
• Respiratory:
  
  • Subjective sense of obstructed airway
    
  • Short of breath
    

• General:
  
  • Fever
    
  • Toxic appearing
    
  • Sitting up in “tripod” stance
    
• Head, eyes, ears, nose, throat:
  
  • “Cherry red” epiglottis is classic, may be pale and edematous in up to 50%
    
  • Hyoid/thyroid cartilage tender to gentle palpation
    
  • Tracheal rock: Pain with movement of the larynx from side to side
    
  • Lymphadenopathy
    
• Respiratory:
  
  • Stridor
    
  • Sudden loss of airway
    
  • Respiratory distress with accessory muscle use
    

If significant respiratory distress:

• Avoid invasive diagnostic procedures
  
• Manage empirically with antibiotics and control of airway prior to further diagnostic evaluation
  

• CBC with differential
  
• Blood cultures
  
• Cultures of pharynx:
  
  • Only if no signs of respiratory distress
    

• In patients with moderate to severe respiratory distress, the airway should be managed prior to imaging
  
• Portable lateral soft tissue x-ray:
  
  • Epiglottic “thumb” sign:
    
    • Thickening of the epiglottis
      
  • “Vallecula” sign:
    
    • The vallecula is normally well-delineated, deep, and roughly parallel to the pharyngotracheal air column
      
    • Absence of a deep and well-defined vallecula, approaching the level of the hyoid bone
      
  • Swelling of the arytenoids and aryepiglottic folds
    
  • Prevertebral soft tissue swelling
    
  • Significant false-negative with imaging
    
  • If suspected with negative film results, rule out with indirect visualization
    
• CT:
  
  • Indicated when a laryngoscopic evaluation cannot be performed or if coexistent soft tissue complications are suspected
    

• Avoid prior to airway management if any signs of respiratory distress are present, including stridor
  
• Nasopharyngoscopy (mini-fiberoptic scope)
  
• Indirect laryngoscopy
  

• Croup
  
• Airway foreign body
  
• Anaphylaxis
  
• Paradoxic vocal cord dysfunction
  
• Angioedema
  
• Laryngitis
  
• Pharyngitis
  
• Oropharyngeal abscess (peritonsillar or retropharyngeal)
  
• Bacterial tracheitis
  
• Congenital anomaly
  
• Meningitis
  

TREATMENT

• Transport patients in position of comfort
  
• Supplemental oxygen as tolerated; avoid increasing anxiety
  
• Intubation indicated only if patient is in severe respiratory distress:
  
  • Likely difficult airway and significant chance of exacerbating compromise with laryngoscopy attempts
    
• Inhaled agents, racemic epinephrine, and β-agonists have no demonstrated value.