A 6-year-old boy is brought to the emergency department due to difficulty breathing. His mother states that he had a mild sore throat yesterday but seemed to respond to over-the-counter analgesics. She adds, "I noticed that my son felt warm, and his voice sounded raspy and hoarse. However, he was sleeping comfortably until an hour ago when he woke up suddenly with rapid, labored breathing." The patient has no cough, runny nose, emesis, or diarrhea. He recently attended a family wedding where several guests were ill. Medical history is significant only for multiple episodes of otitis media and occasional upper respiratory infections. Other than analgesics for this illness, he takes no medications and has not been vaccinated. Temperature is 40 C (104 F), blood pressure is 105/70 mm Hg, pulse is 128/min, and respirations are 46/min. Examination shows an agitated-appearing boy who is leaning forward with his neck extended and mouth open wide. His tongue is protruding, and he is drooling heavily. There is mild inspiratory stridor with no wheezing or crackles, and subcostal and intercostal retractions are present. Heart sounds are normal without murmurs. There are no rashes or skin lesions. Which of the following is the most appropriate next step in management of this patient?

Question

A 6-year-old boy is brought to the emergency department due to difficulty breathing.  His mother states that he had a mild sore throat yesterday but seemed to respond to over-the-counter analgesics.  She adds, "I noticed that my son felt warm, and his voice sounded raspy and hoarse.  However, he was sleeping comfortably until an hour ago when he woke up suddenly with rapid, labored breathing."  The patient has no cough, runny nose, emesis, or diarrhea.  He recently attended a family wedding where several guests were ill.  Medical history is significant only for multiple episodes of otitis media and occasional upper respiratory infections.  Other than analgesics for this illness, he takes no medications and has not been vaccinated.  Temperature is 40 C (104 F), blood pressure is 105/70 mm Hg, pulse is 128/min, and respirations are 46/min.  Examination shows an agitated-appearing boy who is leaning forward with his neck extended and mouth open wide.  His tongue is protruding, and he is drooling heavily.  There is mild inspiratory stridor with no wheezing or crackles, and subcostal and intercostal retractions are present.  Heart sounds are normal without murmurs.  There are no rashes or skin lesions.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf98_438e_8f63_f9ffcfcd6b68_MD0005_00 This unvaccinated child with acute onset of fever, respiratory distress, dysphonia, and stridor, who is drooling and sitting forward with his neck extended (tripod, sniffing position), has the classic presentation of epiglottitis (supraglottitis). Epiglottitis is a bacterial infection of the upper airway resulting in inflammation and edema of the epiglottis. The most common etiologic agent is Haemophilus influenzae type b, which has become less common due to widespread vaccination; however, unvaccinated and incompletely immunized children remain at risk. tripod, sniffing position Epiglottitis is a potentially life-threatening emergency in children, as epiglottis edema can rapidly obstruct the trachea, resulting in respiratory arrest. Emergency airway management is the priority; therefore, preparation for endotracheal intubation is the most appropriate next step in this patient. This is ideally performed in the operating room by an experienced practitioner (eg, anesthesiologist, otolaryngologist). Intravenous antibiotics are administered only after the airway is secure. (Choices A and B) Racemic epinephrine and intramuscular corticosteroids are beneficial for croup (laryngotracheobronchitis), which also can present with stridor and respiratory distress. However, a barking cough is a prominent feature of croup. In addition, fever is minimal and drooling is absent, in contrast to epiglottitis. (Choice C) Lateral neck radiography in epiglottitis reveals a classic "thumbprint sign" due to the edematous epiglottis. However, the diagnosis is usually made based on clinical presentation due to impending respiratory arrest, so intubation should be performed prior to obtaining radiographs. "thumbprint sign" (Choice D) Laryngoscopy provides direct visualization of the edematous, erythematous epiglottis to aid in the diagnosis of epiglottitis; however, attempting this at bedside may cause anxiety and exacerbate respiratory distress. Educational objective: Epiglottitis is a life-threatening infection typically caused by Haemophilus influenzae type b. The classic findings of acute-onset fever, stridor, drooling, and dysphonia indicate impending airway compromise, so immediate endotracheal intubation is critical. References: Airway management in pediatric epiglottitis: a national perspective. (http://www.ncbi.nlm.nih.gov/pubmed/19328345)

A 6-Year-Old Boy Is Brought to the Emergency Department Due