This is a life threatening paediatric emergency.
Early recognition of the diagnosis followed by careful management is essential to prevent sudden, unexpected and potentially fatal airway obstruction.
The treatment of choice is elective nasotracheal intubation until upper airway obstruction and septicaemia have subsided following initiation of appropriate antibiotic therapy.
Symptoms are due to a combination of upper airway obstruction, inflammation and septicaemia. The main differential diagnosis is croup (laryngo-tracheobronchitis). The following are helpful distinguishing features:-
Viral prodrome > 24 hours
Sore throat/dysphagia not prominent
Temperature < 39°C
Usually not toxic
Harsh inspiratory stridor
No neck tenderness
Rapid onset < 24 hours
Cough conspicuously absent
Sore throat/dysphagia/drooling common
Temperature often > 39°C
Soft snoring inspiratory stridor
Tender above larynx
Initial Management of epiglottitis
During history taking and physical examination:
- Do not disturb the child any more than is absolutely necessary. Use your powers of observation. Crying may precipitate acute obstruction.
- Do not enforce lying position. The child will often choose to sit with chin extended and mouth open (look for drooling). Lying could precipitate laryngeal obstruction by swollen epiglottis.
- Do not inspect the throat. Do not use tongue depressor, and do not perform laryngoscopy.
- Do not insert an IV line, or give any injections or oral medication.
- Do not order lateral neck X-ray.
Chest X-Ray can be deferred until after intubation.
- Do not leave the child other than to phone for assistance.
If the diagnosis is suspected on the basis of the history and physical examination call for Senior help immediately:
1. Inform the ED senior, the paediatric Registrar, who will contact the Consultant paediatrician, and call a senior anaesthetist.
2. Management is aimed at avoiding respiratory arrest pending elective intubation in theatre. In the event of collapse due to respiratory arrest, use bag and mask ventilation using oxygen. Proceed to emergency cricothyroidotomy if unable to ventilate and unable to intubate.
Initial Management of croup
- Oxygen by facemask
- Nebulised Racemic Adrenaline 400mcg/kg (max. 5mg)
- Oral dexamethasone 150mcg/kg or Prednisolone 1mg/kg
- Mild cases can go home (discuss with ED Senior or Paediatricians)
- Dexamethasone is a single dose, prednisolone needs a dose the next day also
- Severe cases admit to hospital