Rosen & Barkin's 5-Minute Emergency Medicine Consult (248 page)

• ABCs
  
• Be prepared with all equipment on hand for definitive airway management, including a surgical airway, from presentation until diagnosis is ruled out or transport to intensive care setting
  
• Exam of the airway can trigger airway obstruction
  
• Orotracheal intubation in patients with signs of obstruction or significant respiratory distress:
  
  • Respiratory distress/airway failure may develop precipitously
    
  • Consider ear-nose-throat/surgical consult if patient’s condition permits for possible difficult/surgical airway
    
• Needle jet insufflation may be a life-saving temporizing measure if a surgical airway is not immediately attainable with failed intubation
  

• Humidified oxygen support
  
• IV access, hydration as indicated
  
• Begin antibiotic coverage empirically
  
• Corticosteroids are controversial
  

• Cefotaxime: 2 g IV q8h
  
• Ceftriaxone: 2 g IV q24h
  

• Ampicillin/sulbactam: 3 g IV initially, then 200–300 mg/kg/d in 4 div. doses + vancomycin 1 g IV q12h
  
• Trimethoprim–sulfamethoxazole: 320 mg IV initially, then 4–5 mg/kg IV q12h
  
• Consider adding increased coverage against
  S. aureus:
  
  • Nafcillin: 150–200 mg/kg IV per day in 4 div. doses
    
  • Clindamycin: 600–900 mg IV q8h
    
• Rifampin prophylaxis:
  
  • Adults: 600 mg/d PO for 4 days
    
  • >1 mo of age: 20 mg/kg/d PO for 4 days
    
  • <1 mo of age: 10 mg/kg/d PO for 4 days
    

FOLLOW-UP

Any patient with a suspected or confirmed diagnosis of epiglottitis should be admitted to an ICU setting for IV antibiotics and airway management

• Patients should not be discharged unless the diagnosis has been ruled out by visualization of the supraglottic structures by a physician familiar with physical appearance of the disease
  
• Close contacts should receive prophylactic treatment with rifampin
  

ENT consultation should be obtained

• Failure to manage the airway in a timely manner
  
• Avoid any unnecessary intervention until airway is secured
  
• Mortality is 7% in adults with epiglottitis
  

• Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: Epidemiology, clinical presentation, management and outcome.
  J Laryngol Otol
  . 2008;122:818–823.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2009.
  
• Nentwich L, Ulrich AS. High-risk chief complaints II: Disorders of the head and neck.
  Emerg Med Clin North Am
  . 2009;27:713–746.
  
• Sobol SE, Zapata S. Epiglottitis and croup.
  Otolaryngol Clin North Am
  . 2008;41:551–566.
  
• Tibballs J, Watson T. Symptoms and signs differentiating croup and epiglottitis.
  J Paediatr Child Health
  . 2011;47:77–82.
  
• Woods CR. Epiglottitis. In: Rose BD, ed.
  UpToDate
  . Wellesley, MA: UpToDate; 2012.
  

CODES

• 464.3 Acute epiglottitis
  
• 464.30 Acute epiglottitis without mention of obstruction
  
• 464.31 Acute epiglottitis with obstruction
  

BASICS

• Inflammation of the epiglottis and surrounding supraglottic region, which is potentially life threatening due to progressive airway obstruction
  
• Children are at greater risk of upper airway obstruction owing to:
  
  • Decreased cross-sectional area of the upper airway (resistance is proportional to the inverse of the radius to the 4th power)
    
  • Loose attachment of mucosal surface and increased vascularity of mucosa allows for edema
    
  • Dynamic collapse of the airway
    
• A precipitous decline in the incidence of childhood epiglottitis since the introduction of the
  Haemophilus influenzae
  vaccination has occurred, although vaccine failure may result in rare cases among children who have been immunized
  
• In the post-Hib vaccine era, the mean age for this disease has increased, and it is now more commonly seen in adolescents and adults than in toddlers or young school-aged children.
  
• May occur throughout the year
  

• Infection:
  
  • H. influenzae
    type B
    
  • Streptococcus pneumoniae
    
  • Group A β-hemolytic
    
  • Streptococcus
    
  • Staphylococcus aureus
    
  • Viruses
    
  • Less common infections include Klebsiella, Pseudomonas, Candida
    
• Caustic
  
• Thermal
  
• Traumatic
  
• Post-transplant lymphoproliferative disorder
  
• Hereditary angioedema
  

DIAGNOSIS

• Usually fulminant presentation without prodromal illness
  
• General:
  
  • Irritability, throat pain (often described as patient’s worse sore throat), fever, noisy breathing
    
  • Progressive toxicity and respiratory distress
    
  • Adults have often been previously seen by a physician 1 or more times before diagnosis is made. Adults may present with the “worst sore throat of my life.”
    

• General:
  
  • Toxic appearing
    
  • High fever is typical.
    
  • Rapid onset and progression
    
• Throat:
  
  • Drooling
    
  • Dysphagia
    
  • Muffled “hot potato” voice
    
  • Older patients often have very painful throat.
    
• Respiratory:
  
  • Rapidly progressive respiratory distress (dyspnea in only 1/3 of adults)
    
  • Children usually prefer to sit upright, leaning forward with open mouth (“tripod sniffing position”) to maximize air entry.
    
  • Subtle stridor that may progress to severe stridor (stridor in only 10% of adults)
    
• Complications:
  
  • Airway obstruction is the most severe complication.
    
  • Epiglottic abscess
    
  • Associated pneumonia and atelectasis
    

• Epiglottitis is a clinical diagnosis.
  
• Indirect laryngoscopy or any attempts to directly visualize the epiglottis are not indicated in children with suspected epiglottitis unless performed in a controlled environment. (In adolescents or adults, use of fiberoptic nasopharyngoscope may be indicated for patients without impending airway obstruction.)
  
• If infection is suspected, obtain cultures of the epiglottis during laryngoscopy after airway is secure.
  

• Avoid lab tests until airway is controlled.
  
• Throat cultures after control of airway
  
• Blood cultures after airway is secure:
  
  • Often positive if
    H. influenzae
    is the pathogen
    

• Radiographs of the soft tissue lateral neck:
  
  • Usually not necessary to make the diagnosis
    
  • Creates additional risk by delaying stabilization of the airway, promoting airway obstruction by agitating the patient, and often removing the child from the ED to an uncontrolled environment. Children should never go unaccompanied to radiology. Personnel and equipment to control airway must always be available.
    
• Variable findings:
  
  • Normal
    
  • Swelling of the epiglottis (“thumbprint sign”) and often supraglottic region
    
  • Ballooned hypopharynx
    
  • Obliteration of vallecula
    
  • EW/C3W (epiglottic width to 3rd cervical vertebral body width) ratio of >0.5
    

Laryngoscopy:

• In a controlled environment whenever possible
  
• Cultures of the epiglottis during laryngoscopy after the airway is secured may help identify pathogens and direct treatment.
  
• Epiglottis will appear swollen, inflamed, reddened.
  

• Other infectious processes:
  
  • Bacterial tracheitis
    
  • Retropharyngeal abscess
    
  • Peritonsillar abscess
    
  • Croup (laryngotracheobronchitis)—primarily in younger children, but there is a significant overlap in the ages of presentation.
    
  • Pertussis
    
  • Mononucleosis
    
  • Ludwig angina
    
  • Diphtheria
    
• Anaphylactic reaction with angioedema
  
• Hereditary angioedema
  
• Foreign body in upper airway
  
• Laryngeal trauma
  
• Laryngospasm
  
• Inhalation or aspiration of toxins (e.g., hydrocarbons)
  
• Airway burns (have been related to crack cocaine)
  
• Hyperventilation
  
• CNS disorders