A 3-year-old boy is brought to the emergency department by his parents for evaluation of sudden-onset abnormal breathing and shortness of breath. Yesterday morning, the patient developed a runny nose. Over the past 12 hours, he developed a fever and has had difficulty breathing. Temperature is 40 C (104 F) and respirations are 48/min. Pulse oximetry shows 86% on room air. On physical examination, the patient appears anxious and is sitting up, leaning forward, and drooling. Inspiratory stridor and suprasternal retractions are present. His lips are mildly cyanotic. Which of the following is the best next step in management of this patient?

Question

A 3-year-old boy is brought to the emergency department by his parents for evaluation of sudden-onset abnormal breathing and shortness of breath.  Yesterday morning, the patient developed a runny nose.  Over the past 12 hours, he developed a fever and has had difficulty breathing.  Temperature is 40 C (104 F) and respirations are 48/min.  Pulse oximetry shows 86% on room air.  On physical examination, the patient appears anxious and is sitting up, leaning forward, and drooling.  Inspiratory stridor and suprasternal retractions are present.  His lips are mildly cyanotic.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d5f2_357b_bc81_0173ebf176d2_MD0003_00 Epiglottitis presents with high fever and acute onset respiratory distress, dysphagia, and drooling. Young children are particularly vulnerable to life-threatening airway obstruction due to the narrow caliber of their airways; they may assume the tripod position (ie, sitting, leaning forward, hyperextending neck) to minimize obstruction. Initial management is to secure the airway due to the risk of complete airway obstruction in epiglottitis. The patient should be kept calm, and aggravating interventions (eg, detailed oropharyngeal examination) should be minimized because agitation may cause laryngospasm. In children with respiratory distress (such as this patient with stridor, retractions, and cyanosis), endotracheal intubation should be performed in a controlled setting (eg, emergency department, operating room) with trained personnel (eg, anesthesiologist) available due to the risk of obstruction. Patients may require a surgical airway (eg, tracheotomy, needle cricothyrotomy) if attempts at intubation fail (Choice F). (Choice A) Management of epiglottitis includes administration of broad-spectrum antibiotics (ie, ceftriaxone plus vancomycin). However, the first step in management is to secure the airway in this patient with impending complete upper airway obstruction. (Choices C and E) Corticosteroids and nebulized racemic epinephrine reduce upper airway edema in patients with croup, which classically presents with a "barky," harsh cough and inspiratory stridor without drooling or tripod positioning. These medications do not treat epiglottitis. (Choice D) Epiglottitis can cause visible epiglottal enlargement on lateral neck films (eg, "thumb sign"). However, x-ray is not necessary for diagnosis if clinical suspicion is high, as in this case, and could delay management of impending respiratory failure. Educational objective: Epiglottitis presents with acute onset of respiratory distress (eg, stridor, tripod positioning), dysphagia, and drooling. First-line management of patients with impending respiratory failure is endotracheal intubation in a controlled setting. References: Epiglottitis. (http://www.ncbi.nlm.nih.gov/pubmed/28613691)

A 3-Year-Old Boy Is Brought to the Emergency Department by His