Pediatrics 3: Epiglottitis Portal
PEDS: Because this entire portal pertains only to pediatric patients, the convention of underlining has been omitted.
Diagnostic Considerations
Epiglottitis
is now rare. But when it does occur, epiglottitis most typically
affects children from 2 to 7 years of age, with the most common age
being 3½ years old. The child may progress rapidly into a shock-like
state characterized by pallor, cyanosis, and impaired consciousness.
Causative organisms include Hemophilus influenza, Streptococcus
pneumoniae, Staphylococcus aureus, or group A β-hemolytic
Streptococcus.
Physical Findings
The child with
epiglottitis exhibits fever, dysphagia, and progressive respiratory
distress. Swallowing is painful, secretions accumulate in the mouth,
and drooling is characteristic. Ordinarily, the child prefers to sit
upright with his or her chin forward. As the child attempts to breathe,
you may observe rib retractions. The child frequently has aphonia, but
if she or he does speak, the voice is muffled. Progressive airway
distress may occur rapidly. The airway may close off suddenly.
Patients commonly exhibit moderate to severe respiratory distress with inspiratory and sometimes expiratory stridor. Inspiratory retraction of the intercostal spaces, suprasternal notch, and supraclavicular spaces and subcostal area are present. Patients commonly exhibit nasal flaring. Air hunger leads to restlessness and agitation followed by cyanosis, coma, and even death.
Diagnosis
Due to the severity
of the illness, diagnosis is primarily based on clinical findings. A
lateral x-ray of the nasopharynx and upper airway should demonstrate
the characteristic swollen epiglottis. If x-ray results are normal,
consider croup or foreign body. Have a portable x-ray done in the
resuscitation room rather than sending the child to the X-ray
Department.
Management
- Airway. If the child is relatively stable, wait for an anesthesia and/or ENT specialist to stabilize the airway, ideally in the operating room, if at all possible. If the child must be transported or is decompensating, use RSI (see Vol I—ACUTE CARE PORTALS, Rapid Sequence Intubation) but have transtracheal needle intubation ready.
If orotracheal intubation is not successful, perform transtracheal needle ventilation (Vol II—AIR SKILLS 16 Transtracheal Needle Ventilation) with a pressure setting of about 25 to 30 psi. This may be titrated upward if needed to obtain satisfactory rise and fall of the chest. In infants, it may be necessary to make a vertical incision over the cricothyroid membrane area in order to accurately puncture the cricothyroid membrane or trachea. (Vol II—AIR SKILLS 13 Cricothyrotomy) Use guidewire technique.
While transtracheal needle ventilation is ongoing, re-attempt orotracheal intubation. Now it should be possible to intubate because oxygen will be coming out of the trachea. In some cases, tracheotomy may be needed.
- Additional Care. Obtain throat and blood cultures. Appropriate antibiotics include cefotaxime (Claforan) 50 mg/kg IV every 6 hours or ceftriaxone (Rocephin) 50 mg/kg IV every 12 hours with vancomycin if MRSA is a possibility. Obtain blood and throat cultures. The child will need hospitalization in an intensive care setting. Transfer to a facility with pediatric intensive care and 24-hour per day respiratory specialist.