Tintinalli Tuesday: Upper Respiratory Emergencies

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July 17, 2012 by EmerJencyWEBB

Welcome to the first installment of Tintinalli Tuesday where we will outline a random chapter from “the bible” of emergency medicine and top it off with extra links, media, and pearls!

Upper Respiratory Emergencies

Stridor

  • due to Venturi Effect
  • obstruction may be supraglottic, glottic, subglottic, tracheal, or bronchial in origin
  • inspiratory stridor more common in proximal obstruction
  • expiratory stridor more common in distal airway (aka wheeze)

Differential Diagnosis by Age Group

  • < 6 months typically congenital in origin
    – laryngotracheomalacia (self limited, resolves at age 2)
    – vocal cord paralysis (intubation may be difficult, needle cric may be
    necessary)
    – Chiari II malformation
  • > 6 months typically acquired in origin
    – Inflammatory (i.e. croup, epiglottitis)
    – Foreign Body Aspiration

Epiglottitis

  • Organisms:  H. influenzae, S. pyogenes, S. aureus, and S. pneumoniae
  • Reduction in cases due to H. influenzae vaccine
  • Shift in median age to older children and adults
  • Classic Signs/Symptoms:  High fever, sore throat, stridor, drooling, muffled voice, Tripod Position
  • May be more subtle presentation in older children/adults
  • Keys in Management:  close monitoring, rapid consultation for difficult airway, intubation if necessary by skilled provder in controlled setting
  • Antibiotics: 2nd or 3rd gen. cephalosporins +/- vancomycin
  • FUN FACT:  George Washington died of epiglottitis following a bout of influenzae

Viral Croup

  • aka laryngotracheobronchitis
  • Age range: 6 mo to 3 years
  • Organisms: Parainfluenza virus types I, II, III, Influenza A/B, RSV, rhinovirus, adenovirus
  • Signs/Symptoms:  URI prodrome 1-5 days, then 3-4 day period barking cough, may have biphasic striodor, tachypnea, wheeze
  • Classically days 3-4 are the worst, then improvement is seen
  • Steeple sign on radiograph, although not mandatory for every child
  • Treatment: antipyretic, humidified air (controversial), racemic epi in mod to severe cases (caution in patients with severe LVOT obbstruction, Decadron (0.15-0.6 mg/kg PO)
  • Monitor for at least 3 hours following initial therapy
  • Great Evidence Based Review on Current Treatment Guidelines

Bacterial Tracheitis

  • aka membranous laryngotracheobronchitis
  • secondary bacterial superinfection of viral URI
  • Typical age < 3 years
  • Croup-like prodrome, overtaken by toxic appearance over several hours
  • Signs/Symptoms: cough predominant (unlike epiglottitis), purulent thick sputum, biphasic stridor
  • Management:  similar to epiglottitis

Foreign Body Aspiration

  • Common Aspirants: Food and Toys
  • Vegetable matter may cause profound inflammatory reaction, pneumonitis
  • May have signs/symptoms similar to inflammatory causes of stridor, history is key
  • Unilateral wheezing should clue you into this diagnosis
  • Don’t be fooled with a normal plain film.  However some clues such as unilateral hyperinflation or lobar collapse may be indicators.
  • Treatment:  remove FB typically with bronchoscopy assistance, prepare for difficult airway with appropriate specialty personnel.

Peritonsillar Abscess

  • Typically in older children
  • Signs/Symptoms: fevers, dysphagia, trismus (due to inflammation of pterygoid muscles), drooling, muffled voice, uvular/soft palate displacement
  • Most involve superior aspect of tonsil, and usually tonsil is anteriorly-medially displaced
  • Treatment:  needle aspiration/drainage, antibiotics, pain control
  • Note:  younger children may not be compliant with ED care, and may need to be taken to the OR for definitive drainage.

Retropharyngeal Abscess

  • Age range: 6 months to 4 years due to presence of retropharyngeal lymph nodes
  • May also be secondary to trauma (fall with sharp object in mouth)
  • Potential space bounded by prevertebral fascia and posterior pharyngeal wall and extends to level of  the upper thoracic vertebrae and posterior mediastinum.
  • Symptoms: fever, sore throat, dysphagia, stiff neck (may mimic meningismus), muffled voice, stridor
  • Lateral neck film may show prevertebral soft tissue widening
  • Definitive imaging includes CT scan of neck soft tissues
  • Treatment: ABC’s, ENT consultation for disposition, antibiotics to cover mixed flora including anerobes (augmentin, clinda + 3rd gen ceph)

This chapter outline is from Emergency Medicine: A Comprehensive Study Guide 6th Edition edited by Judith Tintinalli, Gabor Kelen, and J. Stephan Stapczynski. All credit to the material listed above goes to this source.  

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