Eduovisual
CCS Integrated Cases
Epiglottitis: CCS-style airway emergency management
— Pediatric incidence has fallen dramatically since routine Hib (Haemophilus influenzae type b) vaccination in 1985; now <1 per 100,000 in children.
— Adult incidence has risen relatively and is now the predominant demographic, ~1–4 per 100,000 adults annually, peak age 40–50.
— Mortality remains 1–7% in adults, mostly from delayed airway recognition.
— Adults: Streptococcus pneumoniae, S. pyogenes, S. aureus (including MRSA), Hib still possible in unvaccinated.
— Children: Hib in unvaccinated; otherwise S. pyogenes, S. aureus, viral.
— Immunocompromised: think Candida, HSV, pseudomonas.
— Rapidly progressive sore throat out of proportion to oropharyngeal exam (i.e., throat looks normal but patient is in distress).
— Odynophagia + drooling + muffled "hot potato" voice in a febrile adult.
— Tripod positioning, refusing to lie supine, stridor (late finding — ominous).
— Recent thermal/caustic ingestion, recent URI, or unvaccinated child.
— This is a time-critical airway emergency where the wrong move (forcing a tongue blade, supine CT, or sedation without airway team present) can precipitate complete obstruction and death.
— Disposition is always ICU after definitive airway control, never floor or home.
CCS pearl: The instant epiglottitis enters your differential, your first three orders are not labs — they are (1) keep patient upright and calm, (2) page anesthesia and ENT to bedside, (3) move to OR or ICU with intubation equipment ready. Labs and imaging come after airway is secured.
— 30–60-year-old with <24 hours of severe sore throat, fever to 38.5–39°C, odynophagia so severe they cannot swallow secretions → drooling.
— Muffled voice ("hot potato"), NOT hoarse (hoarseness suggests laryngitis/vocal cord pathology).
— Anxiety, leaning forward (tripod), refusing to recline.
— Stridor and respiratory distress are late — their absence does not reassure.
— 2–6-year-old, unvaccinated or incompletely vaccinated, abrupt onset over 4–12 hours.
— High fever, toxic appearance, drooling, tripod position, refusal to speak or swallow.
— Contrast with croup: croup is gradual (1–3 days), barking cough, age 6 months–3 years, viral prodrome, child not toxic.
— Vaccination status (Hib in kids, but also pneumococcal and influenza in adults).
— Timeline — hours, not days, suggests epiglottitis or peritonsillar/retropharyngeal abscess.
— Thermal exposure (crack pipe, scalding liquids, steam) → thermal epiglottitis.
— Caustic ingestion (lye, button battery).
— Immunocompromise (HIV, chemo, transplant, uncontrolled diabetes).
— Recent dental work or URI.
— Drug allergies (you will need to choose an antibiotic shortly).
— Drooling + tripod + muffled voice = "3 D's of impending obstruction" (drooling, distress, dysphagia).
— Stridor at rest.
— Cyanosis or accessory muscle use.
Key distinction: Sore throat out of proportion to a benign-appearing oropharynx is the single most useful historical clue. A normal-looking throat in a toxic, drooling patient is epiglottitis until proven otherwise — do not be reassured by a clean pharyngeal exam.
Board pearl: Adults often present subacutely over 1–2 days and are misdiagnosed as pharyngitis or strep throat at an urgent care; the boards love the "returned to ED" stem with worsening drooling.
— Toxic, anxious, sitting upright in tripod or sniffing position.
— Drooling, pooling oral secretions.
— Tachypnea, tachycardia; hypoxia is a late and ominous sign.
— Muffled "hot potato" voice — supraglottic edema dampens phonation.
— Inspiratory stridor = >50% airway narrowing, near-obstruction.
— Biphasic stridor = critical narrowing, prepare to intubate now.
— Absence of stridor does not rule out — silent obstruction can follow.
— Gently inspect, but do NOT use a tongue blade aggressively in suspected pediatric epiglottitis (can trigger laryngospasm).
— Oropharynx often looks unremarkable — this is diagnostic gold.
— Tender anterior neck on gentle palpation over hyoid/larynx is suggestive.
— Cervical lymphadenopathy may be present.
— Do not force the patient supine (gravity worsens supraglottic obstruction).
— Do not sedate without airway team and surgical airway backup.
— Do not send to radiology unsupervised.
— Do not perform awake fiberoptic exam in agitated child — only by ENT/anesthesia in controlled setting.
— Mallampati, thyromental distance, mouth opening — quick assessment.
— Anticipate difficult intubation: distorted anatomy, edema, friable mucosa, bleeding.
— Plan double setup: oral intubation attempt with immediate surgical airway (cricothyrotomy/tracheostomy) ready in the room.
— Sepsis physiology may coexist — fever, tachycardia, hypotension.
— But hypotension during airway manipulation often = vagally mediated or impending arrest from hypoxia.
CCS pearl: Order continuous pulse oximetry, cardiac telemetry, end-tidal CO₂, and have suction, bag-valve mask, ETTs (one size smaller than predicted), video laryngoscope, fiberoptic scope, and cric tray at bedside before any intervention. Bedside reassessment every 5–10 minutes until airway is secured.
— Classic finding: "thumbprint sign" = swollen, thickened epiglottis.
— Other findings: thickened aryepiglottic folds, ballooning of hypopharynx, loss of vallecular air space.
— Sensitivity ~80% — a normal film does not exclude epiglottitis.
— Obtain upright, portable, with physician escorting patient. Never lay flat for imaging.
— Useful primarily in stable patients to support diagnosis before definitive visualization.
— Performed by ENT or anesthesia, ideally in OR or ICU.
— Visualizes cherry-red, edematous epiglottis and supraglottic structures.
— Allows simultaneous airway assessment and intubation planning.
— Avoid in agitated child until prepared for definitive airway.
— CBC with differential — leukocytosis with left shift.
— BMP — baseline renal/electrolytes for antibiotic dosing.
— Blood cultures × 2 before antibiotics if not yet given — positive in 10–25% of adults, higher in children.
— Lactate — for sepsis screening.
— CRP/procalcitonin — supportive but nonspecific.
— Throat/epiglottic culture — only obtained intraoperatively after airway secured; never swab pharynx in unstable patient.
— Reserve for stable patients to evaluate for abscess (epiglottic, retropharyngeal, parapharyngeal) or to differentiate from deep neck space infection.
— Avoid in unstable airway — supine positioning risk.
Step 3 management: In a toxic, drooling adult, skip the X-ray and go directly to fiberoptic laryngoscopy in a controlled setting (OR/ICU) with surgical airway backup. Imaging is for the equivocal case.
— Performed by ENT under controlled conditions with anesthesia present.
— Combined diagnostic and therapeutic procedure — visualization plus intubation or tracheostomy as needed.
— Allows tissue sampling for culture and exclusion of mass, foreign body, abscess.
— Blood cultures before antibiotics if possible (do not delay antibiotics for cultures in septic patient).
— Epiglottic surface swab during laryngoscopy.
— HIV testing in adults with severe or atypical presentation — epiglottitis can be an AIDS-defining infection (often Candida).
— Consider respiratory viral panel (influenza, RSV, SARS-CoV-2) in atypical cases.
— CT neck with IV contrast once stable: rules out epiglottic abscess (occurs in ~15% of adults, requires drainage), retropharyngeal abscess, Ludwig angina, deep neck infection.
— Chest X-ray post-intubation: confirm ETT placement, evaluate for pneumonia, mediastinitis.
— MRI rarely needed; reserve for suspected mediastinal extension or unusual cases.
— Performed before extubation (typically 24–72 hours after airway control) to confirm resolution of edema and erythema.
— Cuff leak test alone is insufficient.
— Lateral neck: thumbprint = epiglottitis; steeple sign (subglottic narrowing on AP) = croup.
— CT: rim-enhancing collection in retropharyngeal space = retropharyngeal abscess.
— CT: soft tissue gas with floor of mouth involvement = Ludwig angina.
— Recurrent epiglottitis: workup for immunodeficiency, structural anomaly, GERD, allergic etiology.
— Thermal/caustic injury: bronchoscopy and endoscopy may be needed.
Board pearl: A cherry-red epiglottis on fiberoptic exam is pathognomonic — but the test more often hinges on recognizing the clinical syndrome and not delaying airway management for confirmatory studies.
— Stridor at rest, severe respiratory distress, cyanosis, altered mental status.
— Inability to handle secretions, refractory drooling, near-arrest.
— Disposition: OR or ICU with double setup (anesthesia attempts oral intubation; ENT scrubbed for emergent cricothyrotomy/tracheostomy).
— Moderate distress, muffled voice, drooling, but no stridor.
— Significant supraglottic edema on fiberoptic exam.
— Disposition: Controlled intubation in OR with ENT standby.
— Mild symptoms, mild supraglottic edema, handling secretions, stable vitals.
— Adult with subacute presentation.
— Disposition: ICU admission, q15-min vital signs and respiratory assessment, fiberoptic re-exam at 6–12 hours, IV antibiotics, steroids.
— Threshold for intubation should be low — clinical deterioration can be rapid.
— 0 minutes: NPO, upright position, supplemental O₂ via face mask (humidified, blow-by in kids), continuous SpO₂, cardiac monitor, ETCO₂.
— 0–5 min: Page anesthesia + ENT STAT to bedside. IV access × 2 (large-bore if possible without agitating patient).
— 5–15 min: Blood cultures × 2, CBC, BMP, lactate. Do not delay antibiotics beyond 1 hour.
— 15–60 min: Transfer to OR or ICU. Definitive airway assessment and control. Empiric IV antibiotics + IV dexamethasone.
— At 1 hour: Reassess airway, secretions, hemodynamics. If not yet intubated, decide whether to escalate.
CCS pearl: Never "wait and see" alone in a closed exam room. The pediatric or adult patient with suspected epiglottitis must be in a monitored bay with airway team at bedside until definitive airway plan is enacted. Document airway reassessment every 15 minutes until secured.
— Ceftriaxone 2 g IV q24h (covers S. pneumoniae, H. influenzae, S. pyogenes) — first-line.
— PLUS vancomycin 15–20 mg/kg IV q8–12h (target trough 15–20 mg/L) for MRSA coverage, especially in adults or where MRSA prevalence is high.
— Alternatives: cefotaxime 2 g IV q8h, ampicillin-sulbactam 3 g IV q6h, or levofloxacin 750 mg IV q24h for beta-lactam allergy.
— Duration: typically 7–10 days total (IV then oral step-down once afebrile and tolerating PO).
— Add antifungal (fluconazole or echinocandin) if Candida suspected (HIV/AIDS, neutropenia, mucocutaneous candidiasis evident).
— Add acyclovir if HSV suspected on exam (vesicular lesions).
— Dexamethasone 0.6 mg/kg IV (max 10 mg) q6h × 24–48h is commonly used to reduce supraglottic edema, though evidence is mixed (extrapolated from croup data).
— Helpful peri-extubation to reduce post-extubation stridor.
— Continue until extubation criteria met.
— Not standard for epiglottitis (unlike croup).
— May be considered as temporizing measure in extremis while preparing definitive airway — but does not replace intubation.
— Propofol 25–75 mcg/kg/min + fentanyl 25–100 mcg/h infusion.
— Target light sedation (RASS −1 to −2) to allow daily neuro exam.
— Add dexmedetomidine if prolonged intubation anticipated.
— Enoxaparin 40 mg SC daily or heparin 5000 U SC q8h once airway secured.
— Pantoprazole 40 mg IV daily while intubated.
— Acetaminophen 650 mg PO/IV q6h PRN.
— Normal saline or LR at 75–125 mL/h maintenance; bolus if septic.
Step 3 management: Combination ceftriaxone + vancomycin is the modern empiric standard in US adults; do not pick monotherapy with penicillin or ampicillin alone — beta-lactamase–producing H. influenzae and MRSA make this inadequate.
— Anesthesia prepares for awake fiberoptic or inhalational induction intubation.
— ENT/surgery simultaneously scrubbed and ready for emergent cricothyrotomy (adult) or tracheostomy (child <12 or as needed).
— Neck prepped and draped, scalpel and trach tray open before induction.
— Inhalational induction with sevoflurane, patient sitting upright, parent often present until asleep.
— Maintain spontaneous ventilation — do NOT give paralytics until airway visualized and confirmed intubatable.
— Use ETT 0.5–1 size smaller than predicted due to edema.
— Surgical airway = tracheostomy (cricothyroid membrane too small in children <10–12).
— Awake fiberoptic intubation preferred when patient cooperative — preserves spontaneous ventilation.
— Topical lidocaine to oropharynx; minimal sedation (small dose midazolam or dexmedetomidine).
— If rapid sequence needed: ketamine 1–2 mg/kg IV (preserves airway tone) ± rocuronium with sugammadex available for rapid reversal.
— Smaller ETT (6.0–7.0) anticipated.
— "Can't intubate, can't oxygenate" scenario.
— Surgical (scalpel-bougie-tube) technique preferred over needle in adults.
— ETT secured, depth documented; portable CXR to confirm placement.
— ABG at 30 min post-intubation; adjust ventilator (assist-control, TV 6–8 mL/kg IBW, PEEP 5, FiO₂ titrated to SpO₂ >94%).
— Continuous sedation infusion; restraints PRN.
— NG/OG tube placed for gastric decompression and meds.
— Foley catheter, DVT and stress ulcer prophylaxis.
— Afebrile ≥24h, decreasing WBC, fiberoptic re-exam shows resolved supraglottic edema, adequate cuff leak, awake and following commands, hemodynamically stable.
— Extubate in OR or ICU with reintubation equipment and steroids on board.
CCS pearl: The single most important order in suspected epiglottitis is "page anesthesia and ENT STAT to bedside" — listed before any antibiotic, steroid, or lab.
— Often present atypically: less fever, more confusion, gradual sore throat over 2–3 days, delayed diagnosis common.
— Comorbid COPD, CHF, diabetes complicate respiratory reserve — earlier intubation threshold.
— Aspiration risk higher peri-intubation and post-extubation; consider speech/swallow evaluation before resuming PO.
— Polypharmacy: review for immunosuppressants, anticoagulants (affect surgical airway risk).
— Baseline frailty may extend ICU length of stay; engage palliative care early if goals of care unclear.
— Vancomycin: dose by weight, adjust interval by CrCl; target trough 15–20 mg/L; monitor levels q48h and SCr daily.
— Ceftriaxone: no renal adjustment (biliary excretion) — preferred.
— Levofloxacin: reduce dose if CrCl <50 (e.g., 750 mg q48h).
— Avoid aminoglycosides when possible.
— Contrast CT: weigh risk of contrast nephropathy vs diagnostic yield; usually proceed if needed for abscess assessment.
— Ceftriaxone: caution in biliary obstruction (biliary sludging, pseudolithiasis); consider cefotaxime instead.
— Acetaminophen: max 2 g/day in cirrhosis.
— Adjust sedation: propofol preferred over benzodiazepines (less accumulation); avoid prolonged midazolam infusions (delirium, prolonged emergence).
— Broader antimicrobial coverage: consider antifungal and antiviral.
— Lower threshold for intubation — less physiologic reserve.
— Send HIV test, CD4, viral PCRs (HSV, CMV).
— Pseudomonas coverage (cefepime or pip-tazo) if neutropenic.
— Hyperglycemia worsens infection control; target glucose 140–180 mg/dL with insulin infusion if needed.
— Increased risk of Ludwig angina and deep neck infections — ensure CT to exclude.
Step 3 management: In an elderly diabetic with subacute sore throat, drooling, and a benign-appearing pharynx, do not anchor on "viral pharyngitis" — get a lateral neck film or fiberoptic exam and admit to a monitored setting; missed adult epiglottitis is a classic Step 3 morbidity case.
— Now uncommon due to Hib conjugate vaccine (PRP-T or PRP-OMP) given at 2, 4, 6, and 12–15 months.
— Suspect in unvaccinated or under-vaccinated children, recent immigrants, vaccine-refusing families.
— Keep child calm — parent's lap, no IV attempts, no oropharyngeal exam, no separation from caregiver.
— Definitive airway = inhalational induction in OR with ENT and pediatric anesthesia.
— Surgical backup = tracheostomy (not cric).
— Antibiotics: ceftriaxone 50–75 mg/kg IV q24h (max 2 g); add vancomycin 15 mg/kg IV q6h if MRSA suspected.
— Steroids: dexamethasone 0.6 mg/kg IV q6h.
— Rifampin prophylaxis for unvaccinated household contacts <4 years old if Hib confirmed (20 mg/kg PO daily × 4 days).
— Public health reporting for invasive Hib disease.
— Physiologic airway edema and weight gain → already difficult airway baseline; epiglottitis compounds this.
— Left lateral tilt (15°) after 20 weeks gestation if any supine positioning required to avoid aortocaval compression.
— Antibiotic safety: ceftriaxone and ampicillin-sulbactam are category B, safe. Vancomycin acceptable. Avoid fluoroquinolones and tetracyclines.
— Dexamethasone — single course safe; if <34 weeks and preterm delivery anticipated, use betamethasone 12 mg IM × 2 for fetal lung maturity instead.
— Continuous fetal monitoring if ≥24 weeks viability during ICU stay.
— Multidisciplinary team: OB, anesthesia, ENT, neonatology, MFM.
— Bridge between pediatric and adult management; usually can tolerate awake fiberoptic if cooperative.
— Confidential history: substance use (thermal injury from smoking pipes), sexual history (consider GC pharyngitis as mimic).
— Recovery is teachable moment: ensure Hib (if <5y), Tdap, pneumococcal, influenza, COVID-19 vaccines up to date before discharge.
Board pearl: "Unvaccinated 4-year-old, drooling, tripod, muffled voice, low-grade barking absent" → epiglottitis until proven otherwise. Do not examine the throat, do not draw blood, do not get an X-ray — take to OR with parent for inhalational induction.
— Complete airway obstruction and respiratory arrest — leading cause of death.
— Failed intubation requiring emergent cricothyrotomy/tracheostomy — 5–10% of adult cases.
— Post-extubation stridor and reintubation — minimize with steroids, fiberoptic confirmation of edema resolution, cuff leak test.
— Subglottic stenosis — late complication of prolonged intubation; consider tracheostomy if intubation expected >7–10 days.
— Vocal cord injury, dental trauma from difficult laryngoscopy.
— Epiglottic abscess (15% of adults) — requires surgical drainage by ENT.
— Deep neck space infection — retropharyngeal, parapharyngeal abscess; CT to evaluate.
— Mediastinitis — descending necrotizing infection; high mortality; CT chest if persistent fever despite appropriate antibiotics.
— Bacteremia and sepsis — positive blood cultures in 10–25%.
— Pneumonia — aspiration or hospital-acquired.
— Meningitis (especially Hib) — LP if signs/symptoms.
— Epidural abscess, septic arthritis, pericarditis — rare hematogenous spread.
— Ventilator-associated pneumonia — HOB ≥30°, oral chlorhexidine, sedation interruption daily.
— Catheter-associated UTI, central line infection.
— ICU delirium — minimize benzodiazepines, mobilize early.
— DVT/PE — pharmacologic prophylaxis once safe.
— Stress ulcer / GI bleed — PPI prophylaxis while intubated.
— Pressure injuries — q2h turning.
— Adult mortality 1–7%; pediatric mortality <1% in vaccinated era when promptly recognized.
— Most deaths from delayed recognition and out-of-hospital airway loss.
— Survivors generally recover fully if airway controlled before arrest.
— ~5% recurrence rate in adults.
— Workup recurrent episodes for immunodeficiency, GERD, allergic etiology, structural lesion.
Key distinction: Cardiac arrest from airway loss before reaching definitive airway control is the dreaded complication and the rationale for the entire management framework — every step from triage to OR is designed to prevent unmonitored decompensation.
— Anesthesiology — airway management lead.
— Otolaryngology (ENT) — fiberoptic exam, surgical airway backup, definitive diagnosis.
— Critical care / ICU team — admission planning, post-airway management.
— Pediatrics + pediatric anesthesia for children.
— Infectious disease — for atypical, immunocompromised, or treatment-failure cases.
— If presenting facility lacks 24/7 anesthesia and ENT coverage, secure airway BEFORE transfer if any signs of distress.
— EMTALA compliance: stabilize airway first, then transfer.
— Use air or ground critical care transport with intubation-capable team.
— Communicate directly with accepting ICU and ENT attending.
— Send all imaging, cultures, and current medication list.
— Rising FiO₂ requirement despite stable ventilator settings → evaluate for VAP, ARDS, pneumonia.
— New fever or rising WBC after 48–72h → CT neck/chest for abscess, mediastinitis; broaden antibiotics.
— Failed extubation → reintubate, repeat fiberoptic, extend steroids, consider tracheostomy if extubation fails twice.
— Hemodynamic instability → septic shock workup, fluids, vasopressors (norepinephrine first-line).
— Persistent leukocytosis or bacteremia → ID consult, repeat cultures, source control imaging.
— Day 0: ED → OR → ICU intubated.
— Day 1–2: ICU, IV antibiotics, steroids, sedation, daily fiberoptic exams by ENT.
— Day 2–3: Extubation in ICU; observation 24h post-extubation.
— Day 3–5: Transfer to step-down or floor; PO antibiotic transition.
— Day 5–7: Discharge home with oral antibiotics to complete course.
— Any patient with suspected epiglottitis. Period. Even mild cases get admitted to monitored bed.
CCS pearl: Documentation should include explicit airway reassessment notes every 15 minutes until secured, every 2–4 hours while intubated, and every 1–2 hours for 24h post-extubation. Boards reward time-stamped reassessments.
— Age 6 months–3 years; viral (parainfluenza most common).
— Gradual onset over 1–3 days; barking cough, inspiratory stridor, low-grade fever.
— Child not toxic, no drooling.
— Imaging: steeple sign (subglottic narrowing on AP neck X-ray).
— Management: dexamethasone 0.6 mg/kg PO/IM × 1, nebulized racemic epinephrine for moderate-severe; rarely needs intubation.
— Age 6 months–8 years; bacterial superinfection of viral croup, usually S. aureus.
— Toxic, high fever, croup-like cough that worsens despite epinephrine, thick purulent secretions.
— Bronchoscopy diagnostic; ICU admission and broad-spectrum antibiotics (vancomycin + ceftriaxone).
— Often needs intubation for pulmonary toilet.
— Adolescent/adult; unilateral throat pain, trismus, "hot potato" voice, uvular deviation, tonsillar bulge.
— Drooling possible; usually no stridor.
— Management: needle aspiration or I&D, IV antibiotics (ampicillin-sulbactam), discharge often possible.
— Young children 2–4 years (suppurative lymphadenitis) or adults (penetrating trauma, dental).
— Fever, neck stiffness, refusal to extend neck, drooling, muffled voice.
— Lateral neck X-ray: widened prevertebral soft tissue (>7 mm at C2, >14 mm at C6 in kids; >22 mm at C6 in adults).
— CT neck with contrast confirms; surgical drainage by ENT + IV antibiotics.
— Bilateral submandibular/sublingual space infection, usually odontogenic (lower molars).
— Brawny induration of floor of mouth, elevated tongue, trismus, drooling, neck swelling.
— Rapid airway compromise; early intubation (often awake fiberoptic or tracheostomy).
— Polymicrobial; ampicillin-sulbactam ± clindamycin.
— Tonsillar exudate, anterior cervical adenopathy, abnormal-appearing throat — distinguishes from epiglottitis.
— Rapid strep / throat culture diagnostic; penicillin or amoxicillin.
Key distinction: Where is the swelling? Supraglottic = epiglottitis. Subglottic = croup. Retropharyngeal = retropharyngeal abscess. Sublingual/submandibular = Ludwig. Tonsillar = peritonsillar abscess. Mapping the anatomy maps the diagnosis.
— Sudden onset (minutes), exposure history (food, drug, sting), urticaria, angioedema, wheezing, hypotension.
— No fever.
— Treatment: IM epinephrine 0.3–0.5 mg (adult) / 0.15 mg (peds), IV fluids, H1/H2 blockers, steroids, airway support.
— Epiglottitis lacks urticaria and has fever and slower progression.
— Painless swelling of lips, tongue, face; can extend to larynx.
— ACE-I: discontinue drug; supportive ± icatibant or C1-INH (off-label).
— Hereditary: C1 esterase inhibitor concentrate, ecallantide, icatibant.
— No fever, no sore throat predominance.
— Sudden choking, witnessed event, unilateral wheeze or stridor, often toddler.
— Hyperinflation or atelectasis on expiratory CXR.
— Rigid bronchoscopy for removal.
— History of smoke inhalation, crack/marijuana pipe burn, hot beverage, lye ingestion.
— Same airway management principles apply — early intubation.
— Treat underlying injury; antibiotics not always indicated unless secondary infection.
— Adult smoker with subacute hoarseness > weeks, weight loss, neck mass, dysphagia.
— Not acutely febrile.
— Direct laryngoscopy with biopsy by ENT.
— Unvaccinated patient, gray pseudomembrane on tonsils/pharynx, bull neck, low-grade fever.
— Toxin-mediated cardiomyopathy and neuropathy.
— Treatment: diphtheria antitoxin + erythromycin or penicillin; public health reporting.
— Adolescent/young adult, fatigue, posterior cervical adenopathy, splenomegaly, exudative pharyngitis.
— Heterophile (Monospot) or EBV serology.
— Severe tonsillar swelling can rarely cause airway compromise → steroids, airway support.
— Inspiratory stridor without fever, often anxiety-related, young female.
— Diagnosis by laryngoscopy showing paradoxical vocal cord motion; speech therapy.
Board pearl: A painless rapidly progressive upper airway swelling in a patient on an ACE inhibitor is angioedema, not epiglottitis. Pain + fever + drooling = epiglottitis. Painless + lip/tongue + drug history = angioedema.
— Step-down from IV to PO once: afebrile ≥24h, tolerating PO, declining inflammatory markers, extubated and stable.
— Typical PO regimens: amoxicillin-clavulanate 875/125 mg PO BID or levofloxacin 750 mg PO daily for beta-lactam allergic.
— Total duration 7–10 days from initiation.
— Tailor to culture results when available (e.g., MRSA → clindamycin or linezolid).
— Typically not required for short courses (<5 days of dexamethasone). Stop abruptly is fine.
— If longer course used, brief taper.
— Hib vaccine for children per ACIP schedule; catch-up for under-vaccinated.
— Hib vaccine in adults generally not indicated except for asplenia, HIV, complement deficiency, HSCT recipients.
— Pneumococcal vaccine (PCV15/PCV20 or PCV15 + PPSV23) for adults ≥65 or with risk factors.
— Annual influenza vaccine.
— COVID-19 vaccine per current recommendations.
— Tdap if not up to date.
— Smoking cessation counseling and pharmacotherapy (varenicline, bupropion, NRT) — smoking impairs mucosal defenses.
— Diabetes optimization — A1c target <7% (individualized) to reduce infection risk.
— HIV management — start or optimize ART, ensure CD4 trending up.
— GERD treatment if recurrent supraglottitis — PPI trial, lifestyle.
— If invasive Hib disease confirmed AND household contact is unvaccinated child <4y or immunocompromised:
— Rifampin 20 mg/kg PO daily × 4 days (max 600 mg).
— Public health department notification (Hib is reportable).
— Quantitative immunoglobulins, HIV test, vaccine titers, ENT evaluation for structural lesion, allergy testing.
— Consider immunology referral.
— Oral antibiotic completion.
— Acetaminophen/NSAIDs PRN throat pain.
— Topical anesthetic gargles (e.g., viscous lidocaine) for comfort.
— Hydration counseling, soft diet 3–5 days.
Step 3 management: Discharge bundle = complete antibiotics + update vaccinations + smoking cessation + diabetes control + close ENT and PCP follow-up + return precautions. Boards consistently test the vaccination and household prophylaxis pieces.
— Discharge summary to PCP within 48 hours of discharge, including culture results, antibiotic course, extubation timeline, complications.
— Medication reconciliation with patient/family at bedside before discharge.
— Written discharge instructions in patient's preferred language and literacy level.
— PCP visit within 1 week of discharge: review symptoms, medication adherence, vaccination updates, smoking cessation, diabetes/HIV management.
— ENT follow-up at 2–4 weeks: repeat fiberoptic laryngoscopy to confirm complete resolution, assess for vocal cord injury or subglottic stenosis from intubation.
— Infectious disease follow-up at 2–4 weeks for immunocompromised or unusual organisms.
— Repeat labs at 1 week: CBC, CRP to confirm normalization.
— Recurrent sore throat with fever, difficulty swallowing, drooling.
— Stridor, voice change, neck swelling.
— Persistent fever >48h after discharge.
— Inability to tolerate PO antibiotics.
— Voice/swallow evaluation if any post-extubation hoarseness or aspiration symptoms — speech-language pathology referral.
— Pulmonary function testing if any persistent dyspnea — rule out subglottic stenosis.
— Annual influenza vaccine and ongoing routine immunizations.
— Most patients fully recover within 2–4 weeks.
— Recurrence rare but possible; recognize early symptoms.
— Smoking cessation reduces recurrence and overall airway disease risk.
— Ensure HPV, COVID, flu, pneumococcal vaccines current.
— For caregivers of children: maintain Hib vaccination schedule on time; recognize symptoms.
— Post-ICU syndrome: cognitive, physical, psychological sequelae after prolonged ICU stay.
— Refer for pulmonary rehab if deconditioned; PT/OT for ICU-acquired weakness.
— Screen for PTSD and depression at 4–6 weeks (PHQ-9, PCL-5) — survivors of acute airway events have elevated rates.
— Coordinate prescriptions through preferred pharmacy; verify insurance coverage of oral antibiotics before discharge to avoid readmission for noncompliance.
— Transitional care management (TCM) billing supports the 1-week follow-up visit and care coordination.
CCS pearl: A complete Step 3 follow-up plan documents who (PCP, ENT, ID), when (1 week, 2–4 weeks), what (fiberoptic re-exam, labs, vaccines, smoking cessation), and return precautions in writing — incomplete follow-up plans lose points even on otherwise strong cases.
— When patient cannot provide consent due to impending airway loss, proceed under implied/emergency consent doctrine — reasonable person would consent to life-saving airway intervention.
— Document the emergency and rationale clearly in chart.
— Update surrogate decision-maker (next of kin, healthcare proxy) as soon as feasible.
— For elective extubation, intubation timing in non-emergent supraglottitis, or tracheostomy decisions, obtain formal consent from patient or surrogate.
— Parental consent required; in true emergency, proceed and document.
— Adolescent assent when developmentally appropriate.
— Mature minor doctrine varies by state — relevant for adolescents refusing care.
— Document discussion of Hib vaccine importance with vaccine-refusing parents using shared decision-making framework.
— Provide VIS (Vaccine Information Statement).
— Do not refuse to treat the child; engage public health if pattern of medical neglect.
— Invasive Hib disease is reportable to local/state health department (varies by jurisdiction).
— Suspected caustic ingestion in a child → child protective services if concern for abuse/neglect.
— Document poison control consultation.
— Handoff failures between ED, OR, ICU, floor, and outpatient are the highest-risk moments. Use structured handoff (I-PASS, SBAR).
— Medication reconciliation at every transition — especially anticoagulants held for airway procedures must be restarted appropriately.
— Read-back verification of critical airway plans between teams.
— Time-out before any airway procedure.
— Dental injury, vocal cord injury, failed extubation, prolonged ICU stay — disclose promptly per institutional policy.
— Apology with empathy, factual description, plan to prevent recurrence.
— Emergency department must stabilize (secure airway) before transfer regardless of insurance status.
— Transfer must be medically appropriate with accepting facility and physician agreement.
— Avoid unnecessary CT in patients without abscess suspicion.
— Right-size antibiotic duration (7–10 days, not longer) — antimicrobial stewardship.
— In elderly or severely comorbid patients, goals-of-care discussion before tracheostomy is essential; involve palliative care.
— Respect existing advance directives and POLST — but recognize that reversible airway obstruction in a patient with otherwise good quality of life may warrant intervention even with prior DNR/DNI if surrogate concurs (clarify language).
Step 3 management: A patient with a DNI order presenting with acute epiglottitis requires immediate goals-of-care reclarification: many DNI orders were written for chronic terminal illness and patients/surrogates may accept short-term intubation for a reversible infection. Document the conversation, the surrogate's name, and the revised plan before proceeding.
— Thumbprint sign — lateral neck X-ray, epiglottitis.
— Steeple sign — AP neck X-ray, croup.
— Cherry-red epiglottis — fiberoptic visualization.
— Hot potato voice — muffled phonation from supraglottic edema.
— Tripod position / sniffing position — patient self-optimization for airway patency.
— 3 D's — drooling, dysphagia, distress.
— Unvaccinated child → Hib.
— Vaccinated child or adult → S. pneumoniae, S. pyogenes, S. aureus (incl. MRSA).
— Immunocompromised → Candida, HSV, Pseudomonas.
— Post-burn/thermal → sterile inflammation ± secondary bacterial.
— Suspected epiglottitis → don't examine throat with tongue blade in a child; call anesthesia + ENT.
— Drooling adult with sore throat → lateral neck X-ray or direct fiberoptic exam.
— Pediatric induction → inhalational sevoflurane, spontaneous ventilation preserved.
— Surgical airway in adult → cricothyrotomy; in child <10 → tracheostomy.
— Empiric: ceftriaxone + vancomycin.
— Pregnancy: ceftriaxone + vancomycin OK; avoid fluoroquinolones.
— Penicillin allergy: levofloxacin.
— Hib contact prophylaxis: rifampin × 4 days.
— Every epiglottitis case → ICU, no exceptions.
— Total LOS typical: 5–7 days.
— Total antibiotic duration: 7–10 days.
— Hib vaccine: 2, 4, 6, 12–15 months.
— Adult Hib vaccine indicated only for: asplenia, HIV, complement deficiency, HSCT.
— Delayed recognition (most common).
— Failed airway in uncontrolled setting.
— Sepsis from delayed antibiotics.
— Dexamethasone standard for both epiglottitis (extrapolated) and croup (evidence-based).
— Racemic epinephrine = croup, not epiglottitis (except as last-ditch temporizer).
— Immunoglobulins, HIV, allergy, GERD, structural ENT eval.
Board pearl: The single highest-yield Step 3 testable point is that a toxic-appearing patient with sore throat out of proportion to a benign pharyngeal exam needs immediate airway team activation, NPO, upright position, ICU disposition — even before any imaging or labs.
— 45-year-old man seen at urgent care for "strep throat" yesterday on amoxicillin, now returns with worsening sore throat, drooling, muffled voice, tripod position. Oropharyngeal exam unremarkable, T 38.7°C, HR 115, SpO₂ 95%.
— Best next step: Call anesthesia and ENT for fiberoptic laryngoscopy and airway management in OR; not another antibiotic prescription, not CT scan, not tongue blade exam.
— 3-year-old, unvaccinated by parental choice, 6-hour history of high fever, refuses to swallow, drooling, sits leaning forward. Vital signs show distress.
— Best next step: Do not examine throat, do not start IV, do not order labs in the ED. Keep child with parent, give blow-by O₂, transport to OR for inhalational induction with anesthesia + ENT present.
— Likely organism: Hib.
— Household contact prophylaxis: Rifampin × 4 days for unvaccinated children <4 years in the home.
— Lateral neck X-ray shows thumbprint sign. Diagnosis?
— Epiglottitis. Next step is fiberoptic exam and airway control, not CT.
— Hospitalized adult with confirmed epiglottitis. Which empiric regimen?
— Ceftriaxone + vancomycin (covers Hib, pneumococcus, MRSA).
— Intubated patient day 2; afebrile 24h, WBC trending down, what determines extubation readiness?
— Fiberoptic laryngoscopy showing resolution of supraglottic edema plus standard extubation criteria (cuff leak, awake, hemodynamically stable).
— Child with barking cough, low-grade fever, gradual onset, steeple sign → croup, not epiglottitis. Treatment: dexamethasone ± racemic epinephrine.
— Adult on lisinopril with tongue and lip swelling, no fever, no sore throat → ACE-I angioedema, not epiglottitis. Stop drug, supportive airway care.
— Adult survivor of epiglottitis, asplenic. Which vaccine indicated?
— Hib, pneumococcal (PCV20 or PCV15+PPSV23), meningococcal (MenACWY + MenB) — encapsulated organism protection.
— Patient with DNI order presents with epiglottitis. Action?
— Reclarify goals of care with patient/surrogate; reversible illness may warrant short-term intubation if patient/surrogate agrees.
Step 3 management: When a stem describes drooling + muffled voice + benign pharynx + fever, your answer is always airway team and ICU, not antibiotics first, not CT first, not throat exam first.
Epiglottitis is an airway emergency where suspicion alone — sore throat out of proportion to a benign pharyngeal exam, drooling, muffled voice, tripod posture — mandates immediate anesthesia and ENT activation, upright NPO positioning, OR-based definitive airway control with surgical backup, empiric ceftriaxone plus vancomycin, dexamethasone, and ICU admission, with disposition and follow-up structured around extubation confirmed by fiberoptic resolution of supraglottic edema and outpatient ENT/PCP follow-up at 1 and 2–4 weeks.
Board pearl: Of every diagnostic and therapeutic decision in epiglottitis, only one is truly time-critical — securing the airway in a controlled OR setting with anesthesia and ENT present — everything else (antibiotics, steroids, imaging, labs, cultures) is secondary and must never delay it.