EPIGLOTTITIS

Question 1

Approach to the Critically Ill Epiglottitis

Answer 1

Monitor
Oxygen
Vitals
IV Access
Equipment: Airway

AIRWAY
Rapid Bedside Assessment:
Drooling
Voice change
Stridor
Inability to speak
Tripod or sniffing positioning
Hypoxia
Swelling of the posterior oropharynx
Inability or unwillingness to lie flat

Position upright, head tilt / chin lift

Secure Airway in patients with impending airway obstruction

Awake / Nasal Intubation if Limited oral access

Fiberoptic Visualization > Video Laryngoscopy > Direct

Prepare for surgical airway PRIOR to non-surgical airway

Dexamethasone 0.6 mg/kg (10 mg)
OR
Methylprednisone 2-3mg / kg (125 mg)

Combination antibiotic therapy including 3rd generation cephalosporin and methicillin-resistant Staph Aureus Coverage

Adult

Cefotaxime 2 g IV q 8
OR
Ceftriaxone 2 g IV q 24 PLUS
Vancomycin loading dose 25 - 30 mg/kg IV followed by 15-20 mg/kg IV q 8-12 hr
(max dose 2 g).

Pediatric

Cefotaxime 50 mg/kg IV q 8 hr (maximum dose 2 g)
OR
Ceftriaxone 50 mg/kg IV q 24 hours (max dose 1 g)
Plus
Vancomycin 60-80 mg/kg per day IV divided every 6-8 hours (maximum dose 2 g).

Serial Airway Assessment

Urgent ENT Consult for further visualization/urgent nasopharyngeal scope/laryngoscopy in stable patients

CIRCULATION
Bolus 30 ml / kg Crystalloid if needed

Question 2

Critical DDx

Answer 2

Angioedema
Bacterial Tracheitis
Diphtheria
Epiglottitis
Lemierre Syndrome
Ludwig Angina
Mononucleiosis
Peritonsillar Abscess
Retropharyngeal Abscess
Uvulitis

Question 3

History & Physical: Adults

Answer 3

Sore Throat (67-89%)
Dysphagia (71%)
Odynophagia (58-100%)
Dysphonia (50-56%)
Fever (55%)
Dyspnea (46-58%)
Drooling (35-83%)

Ask about neck pain

Question 4

History & Physical: Pediatrics

Answer 4

Fever (83%)
Stridor (83%)
Sore Throat (67%)
Dysphagia (67%)
Drooling (67%)
Dyspnea (50%)
Odynophagia (17%)
Dysphonia (17%)

Ask about neck pain

Question 5

Investigations

Answer 5

Consider:

Lateral neck XRAY

CT Neck with IV Constrast

Question 6

Management

Answer 6

Intubation should be done in the operating room

Dexamethasone 0.6 mg/kg (10 mg)
OR
Methylprednisone 2-3mg / kg (125 mg)

Combination antibiotic therapy including 3rd generation cephalosporin and methicillin-resistant Staph Aureus Coverage

Adult

Cefotaxime 2 g IV q 8
OR
Ceftriaxone 2 g IV q 24 PLUS
Vancomycin loading dose 25 - 30 mg/kg IV followed by 15-20 mg/kg IV q 8-12 hr
(max dose 2 g).

Pediatric

Cefotaxime 50 mg/kg IV q 8 hr (maximum dose 2 g)
OR
Ceftriaxone 50 mg/kg IV q 24 hours (max dose 1 g)
Plus
Vancomycin 60-80 mg/kg per day IV divided every 6-8 hours (maximum dose 2 g).

Question 7

Disposition

Answer 7

Admission