EM@3AM – Epiglottitis

Author: Erica Simon, DO, MHA (@E_M_Simon, EMS Fellow, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 6-year-old male presents by EMS to the emergency department for respiratory distress. The patient’s aunt, caring for the child while he is on holiday from Mexico, reports the acute onset of fever and sore throat two days prior to arrival. Per the family member, the child awoke gasping with “loud noises coming from his throat.”

Upon presentation the child is toxic appearing. He is seated in a tripod position and has audible stridor.

What’s the next step in your evaluation and treatment?

Answer: Epiglotitis^1,2

• Epidemiology: Considered a disease of adults in the U.S. (90-95% of cases¹), and in areas which practice routine infant immunization. Incidence of adult epiglottitis in the U.S. and Europe: 2 cases per 100,000 population.¹
• Clinical Manifestations and Pathogens:
  • Pediatric epiglottitis: Febrile illness commonly characterized by odynophagia, dysphagia, drooling, stridor, and often “tripod” positioning to maintain airway patency.^1,2
    • Most common pathogen: H. influenza type B (associated bacteremia occurs in 60-98%¹).
  • Adult epiglottitis: Frequently manifests as odynophagia and dysphagia.^1,2 Fever, drooling, and stridor have been reported in 20-40% of patients.¹ Associated bacteremia is uncommon.¹
    • Pathogens uncommonly isolated from culture. When growth on culture media occurs species most often isolated include S.pneumoniae, S. pyogenes, and N. meningitidis.¹
  • Evaluation and Treatment:
    • Assess the ABCs and obtain vital signs.
      • Pediatric patient: If concern for airway compromise, defer until definitive airway is obtained (ENT consult => OR for direct laryngoscopy and intubation).
      • Adult patient:
        • Toxic with signs of airway compromise: ENT consult => awake, fiberoptic intubation preferred (cricothyrotomy second line).
      • May consider neck radiographs (“thumb print sign”) and laboratory studies (CBC demonstrating leukocytosis common¹) in the stable patient.
      • Following airway establishment: obtain blood cultures, and if possible swab the epiglottis (targeted antibiotic therapy¹).
      • Treatment: third-generation cephalosporin (ceftriaxone or cefotaxime) or β-lactamase inhibitor (ampicillin-sulbactam) + vancomycin if penicillin-resistant pneumococci present or if MRSA bacterial tracheitis suspected.¹
        • Immunocompromised patients: pipercillan-tazobactam.¹
•  Pearls:
  • Chemoprophylaxis is advised for household contacts of children with H. influenza type B who are ≤ 4 years of age, underimmunized, or non-immunized, or children of any age who are immunocompromised:
    • Rifampin: 20 mg/kg/day (max 600mg) once PO QD for 4 days duration.¹

 References:

1. Najak J, Weinberg G. Epiglottitis. In Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8^th ed. Philadelphia, Saunders. 2015; 64,785-788.e1.
2. Hern H. Pharynx and Throat Emergencies. In Emergency Medicine Clinical Essentials. Philadelphia, Saunders. 2013; 29,249-258.e1.

For Additional Reading:

Management of Epiglottitis in the Community Setting:

Management of Epiglottitis in the Community Setting