Pediatric emergency medicine trisk 2278 2278

Many clinical entities can be differentiated on the basis of the child’s age, history, and oropharyngeal
examination.
Airway instrumentation in a child with suspected epiglottitis should be performed in the more
controlled environment of the operating room.
Many upper airway infections are caused by streptococcal and staphylococcal species, simplifying
empiric ED antibiotic selection.
Epiglottitis
Epiglottitis is characterized by fever, drooling, dysphagia, and inspiratory stridor in a toxic-appearing child who is
not hoarse and does not have a barky cough. The illness is rapidly progressive over hours and is most common in
children 1 to 8 years of age. The most common organism historically was Hib, but now S. pneumoniae,
Streptococcus pyogenes, and S. aureus comprise many of the cases. Soft tissue lateral neck radiographs can show
an enlarged epiglottis (“thumbprint sign”), and visualization demonstrates a swollen, erythematous epiglottis.
However, instrumentation is best performed in the operative setting to prevent airway compromise. Immediate
involvement of otolaryngology and broad-spectrum antibiotics (e.g., vancomycin and cefotaxime) and attempting
to keep the child calm are the mainstays of ED management. Standard precautions should be used.
Retropharyngeal Abscess
Retropharyngeal abscesses (RPAs) are characterized by nuchal rigidity or torticollis, difficulty swallowing,
drooling, stridor, and fever. Anterior bulging of the posterior pharynx can be difficult to appreciate. Children with
RTAs usually are preschool aged, and GAS and S. aureus are the most common organisms. A soft tissue lateral
neck radiograph can suggest the diagnosis if there is increased prevertebral space; however, a contrast CT neck is
better to delineate the anatomy prior to operative intervention. Empiric antibiotics should target streptococci and
staphylococci (e.g., clindamycin). Standard precautions should be used.
TABLE 94.12
PRESENTATION OF AIRWAY AND NECK INFECTIONS

Peritonsillar Abscess
Peritonsillar abscesses (PTAs) are characterized by unilateral swelling of the tonsils, change in caliber of the voice,
trismus, unilateral odynophagia, displacement of the uvula toward the unaffected side, and fever. PTAs are most