RT Book, Section
A1 Soder, Christian M.
A1 Johnson, Liane B.
A2 Hung, Orlando
A2 Murphy, Michael F.
SR Print(0)
ID 55871879
T1 Chapter 43. Airway Management of a Child with Supraglottitis
T2 Management of the Difficult and Failed Airway, 2e
YR 2012
FD 2012
PB The McGraw-Hill Companies
PP New York, NY
SN 978-0-07-162344-5
LK accessanesthesiology.mhmedical.com/content.aspx?aid=55871879
RD 2023/10/01
AB A  previously  healthy  4-year-old  boy  is  en  route  to  the  children's  hospital  via  helicopter.  He  was  well  until  8  hours  ago  when  he  began  to  complain  of  sore  throat  and  pain  on  swallowing.  His  mother  brought  him  to  the  local  emergency  department  (ED).  The  emergency  physician  on  duty  met  a  sick,  flushed,  aphonic,  and  fearful  boy  who  sat  very  still  and  reluctantly  swallowed  his  saliva  with  visible  effort  and  discomfort.  He  had  no  visible  respiratory  distress  or  stridor.  He  was  able  to  lie  down  on  request  but  preferred  to  sit.  His  temperature  was  39.6°C,  BP  142/75  mm  Hg,  and  HR  145  bpm.  Examination  of  the  chest  revealed  no  signs  of  distress,  but  coarse  ronchi  were  audible  on  auscultation.  The  throat  was  not  examined  and  the  remainder  of  the  general  physical  examination  was  negative.  On  direct  questioning,  the  mother  admitted  that  she  did  not  believe  in  vaccinations  and  that  their  children  had  not  received  the  hemophilus  influenza  B  (HIB)  vaccine.  The  ED  physician  suspected  supraglottitis  and  called  for  an  emergency  transfer  to  the  nearest  children's  hospital.  While  waiting  for  the  helicopter  to  arrive,  the  physician  started  an  IV,  administered  0.6  mg·kg−1  of  dexamethasone,  25  mg·kg−1  of  ceftriaxone,  and  started  oxygen  40%  by  face  mask.  During  transport,  the  air  medical  crew  administered  epinephrine  aerosols  every  20  minutes.  The  transport  was  uneventful  but  it  was  noted  that  the  boy  was  developing  moderate  indrawing  and  was  insisting  on  sitting  up.  His  pulse  oximeter  read  100%  on  oxygen  4.0  L·min−1  flow,  by  non-rebreathing  face  mask,  throughout  the  flight.  He  arrived  in  the  ED  at  the  children's  hospital  after  a  25-minute  flight.  On  examination,  the  physical  findings  were  as  before  but  the  boy  had  now  adopted  the  classic  tripod  sniffing  position.  His  breath  sounds  were  muted,  he  was  visibly  drooling,  and  he  maintained  a  posture  of  fearful  rigidity.  When  made  to  speak,  he  had  a  muffled  hot  potato  in  the  mouth  voice.  Chest  examination  revealed  mild  intercostal  and  sternal  notch  indrawing.  Without  supplementary  oxygen  his  oxygen  saturation  by  pulse  oximeter  dropped  to  89%.  After  preliminary  assessment,  he  was  transferred  immediately  to  the  operating  room  for  airway  management.  No  lateral  neck  airway  radiographs  were  taken.