Rosen & Barkin's 5-Minute Emergency Medicine Consult (249 page)

TREATMENT

Degree and mode of intervention must reflect degree of obstruction, time and means of transport, capability of care providers, etc. Consult and notify receiving hospital.

• Airway management if patient is in extremis
  
• Bag-valve-mask ventilation with 100% O
  ₂
  with cricoid pressure often provides adequate ventilation and time to prepare for intubation and move to a controlled setting such as the operating room.
  
• Oral intubation:
  
  • Use an endotracheal tube (ETT) size that is 1 or 2 sizes smaller than indicated by age or length.
    
  • Direct compression of the anterior neck in the glottic region may help visualize air bubbles at the opening of the swollen glottis.
    
  • Instruments used for difficult airways may be adjunctive devices.
    
• If oral intubation fails:
  
  • Emergent cricothyrotomy or needle cricothyrotomy if age older than 10–12 yr
    
  • Needle cricothyrotomy if age younger than 10–12 yr
    

• 100% O
  ₂
  as tolerated by patient
  
• Allow child to remain in position of comfort and do not force child to lie down, which may worsen airway obstruction.
  
• Although not proven, racemic epinephrine or L-epinephrine by nebulizer may temporize symptoms while plans for a definitive airway are rapidly arranged. It must be done with caution to avoid agitating the child.
  
• Avoid procedures that agitate the child such as IV access and blood draws.
  
• Empiric invasive airway management may be indicated:
  
  • Patients with rapidly progressive respiratory difficulty, tachypnea, worsening throat pain, tachycardia, or hypoxemia
    
  • Patients at high risk of acute obstruction (e.g., children with immunodeficiency disorders)
    
• Intubate in operating room or controlled environment by most skilled person.
  
• Use inhalational anesthesia before intubation.
  
• Have appropriate ETTs of various diameters of available to accommodate the inflamed supraglottic region.
  
• Surgical backup is required in case intubation is not possible; then emergency tracheotomy or cricothyrotomy can be performed.
  
• Equipment for intubation and for a surgical airway or needle cricothyrotomy must be available at the bedside.
  
• Administer IV antibiotics: 2nd- or 3rd-generation cephalosporins are active against β-lactamase–producing
  H. influenzae.
  
• Steroids are controversial but frequently administered, particularly in patients with chemical or thermal epiglottitis.
  

• Ampicillin/sulbactam: 200–300 mg/kg/24h q6h IV
  
• Cefotaxime: 150 mg/kg/24h q6–8h IV
  
• Ceftriaxone: 100 mg/kg/24h q12h IV
  

• Ampicillin: 100–200 mg/kg/24h q6h IV given with chloramphenicol
  
• Chloramphenicol: 75–100 mg/kg/24h q6h IV
  
• Meropenem: 120 mg/kg/24h q8h max. dose 6 g/24h
  
• Decadron: 0.6 mg/kg/d (max. 10 mg) IV.
  
  • Steroid use is controversial
    
• Epinephrine, racemic: 0.05 mL/kg (max. 0.5 mL) q30min in 2.5 mL normal saline (NS) via nebulizer
  
• L-epinephrine, 1:1,000: 0.5 mL/kg (max. 5 mL) q30min via nebulizer
  
• Rifampin for household contact prophylaxis: 20 mg/kg (max. 600 mg) daily for 4 days
  
• If hereditary angioedema is the suspected cause of epiglottitis, C1 esterase inhibitor concentrate (alternatively, if C1-INH is not available, consider fresh frozen plasma). Expert consultation recommended
  

FOLLOW-UP

Patients with suspected or proven epiglottitis should be admitted to ICU after stabilization of airway and administration of antibiotics and fluids.

• Rifampin prophylaxis may be indicated for close contacts of
  H. influenzae
  epiglottitis. If the household has children younger than 12 mo of age or children who are unimmunized, incompletely immunized, or immunosuppressed, prophylaxis is indicated for nonpregnant household contacts. Child care center contacts should receive prophylaxis when 2 or more cases of Hib invasive disease have occurred within 60 days.
  
• All cases of invasive
  H. influenzae
  disease should be reported to the local or state public health department.
  

Critical care or pulmonary consult on all patients

True airway emergency. Patient must be monitored and accompanied at all times by someone with airway stabilization capabilities.

• American Academy of Pediatrics.
  Red Book: 2012 Report of the Committee on Infectious Diseases
  . 29th ed. Elk Grove Village, IL: AAP; 2012.
  
• Faden H. The dramatic change in the epidemiology of pediatric epiglottitis.
  Pediatr Emerg Care
  . 2006;22:443–444.
  
• Grover C. Images in clinical medicine. “Thumb sign” of epiglottitis.
  N Engl J Med
  . 2011;365:447.
  
• Hopkins A, Lahiri T, Salerno R, et al. Changing epidemiology of life-threatening upper airway infections: The reemergence of bacterial tracheitis.
  Pediatrics.
  2006;118:1418–1421.
  
• O’Bier A, Muñiz AE, Foster RL. Hereditary angioedema presenting as epiglottitis.
  Pediatr Emerg Care.
  2005;21:27–30.
  
• Rafei K, Lichenstein R. Airway infectious disease emergencies.
  Pediatr Clin North Am.
  2006;53:215–242.
  
• Shah RK, Roberson DW, Jones DT. Epiglottitis in the
  Hemophilus influenzae
  type B vaccine era: Changing trends.
  Laryngoscope
  . 2004;114:557–560.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Bacterial Tracheitis
  
• Croup
  
• Epiglottitis, Adult
  

CODES

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

BASICS

• Fractures through the physis accounts for 21–30% of pediatric long bone fractures with 30% of these leading to a growth disturbance:
  
  • Most frequently seen in the distal radius and ulna, distal tibia and fibula, and the phalanges
    
  • More common than ligamentous injury in children:
    
  • Tensile strength of pediatric bone is less than adjacent ligaments.
    
  • Physis is the weakest part of pediatric bone.
    
  • Similar injury in an adult usually causes a sprain.
    
• Most common during peak growth:
  
  • Females: Age 9–12
    
  • Males: Age 12–15
    
  • Much less common in infancy and early childhood because epiphysis is not ossified and acts as a shock absorber
    
• Twice as common in males because female bones mature earlier
  
• Salter–Harris (SH) classification (introduced in 1963, simplest and most commonly used classification system):
  
  • Type I:
    
    • Fracture line confined to physis
      
    • Complete epiphyseal separation from metaphysis through the physis
      
    • If periosteum remains intact, epiphysis will not displace.
      
    • Clinical diagnosis made with focal tenderness over the physis
      
    • Most common example is SCFE.
      
    • Growth disturbance is rare.
      
  • Type II:
    
    • Accounts for ∼80% of physeal fracture patterns
      
    • Fracture propagates along physis, and fragment from metaphysis accompanies the displaced epiphysis (Thurston–Holland sign)
      
    • Periosteum torn opposite metaphyseal fragment
      
    • Growth is rarely disturbed.
      
  • Type III:
    
    • Rare
      
    • Fracture through a portion of physis extending through the epiphysis
      
    • Distal tibia most commonly affected
      
    • If displaced, requires reduction to maintain anatomic alignment
      
    • Growth disturbance may occur despite anatomic reduction because blood supply can be affected.
      
  • Type IV:
    
    • Fracture originates at articular surface.
      
    • Extends through physis and into metaphysis
      
    • Distal humerus most commonly affected
      
    • Also has Thurston–Holland fragment
      
    • Anatomic reduction essential and displaced fractures require ORIF
      
    • Growth arrest is common even with optimal treatment.
      
  • Type V:
    
    • Results from severe crush injury to physis
      
    • No immediately visible radiographic alteration so almost impossible to diagnose initially
      
    • Compression forces lead to physeal injuries and inevitable growth disturbances.
      
    • Often found in retrospect
      
• Ogden modified the SH system to include injuries to the surrounding anatomy—periosteum, perichondrium, and zone of Ranvier:
  
  • Ogden Type VI: Involves the peripheral perichondrium including the zone of Ranvier
    
  • Ogden Type VII: Involves epiphysis only
    
• Peterson classification system, 1994:
  
  • Result of a 10 yr retrospective study
    
  • Showed that 16% of physeal injuries could not be classified by the SH system
    
  • Includes 2 different fracture patterns:
    
    • Peterson Type I—transverse fracture through the metaphysis with 1 or more longitudinal extensions into the physis (this is similar to SH II except most of the energy is transmitted through the metaphysis, leading to a fracture, and not the physis; there is very little growth plate disturbance, this was actually the most common fracture pattern found)
      
    • Peterson Type VI—a part of the epiphysis, physis, and metaphysis are missing due to an open injury, classically by a lawnmower. Severe growth disturbance.
      
    • Peterson Types II–V are similar to the SH II–V.