01Approach to the Critical Patient/attcp34

Immediate priorities

›Airway and resuscitation priorities

›High risk upper airway obstruction

›Immediate airway team activation for stridor or drooling or tripod or voice change

›If significant distress, resuscitation bay and continuous observation

›Oxygenation and ventilation support

›Supplemental oxygen to maintain SpO2 per local targets

›Bag mask ventilation readiness with 2 person technique

›Positioning and agitation minimization

›Upright position of comfort

›Avoid forced supine positioning

›Monitoring and access

›Continuous pulse oximetry and ECG

›Two large bore IV lines if tolerated

Airway strategy

›Controlled airway plan

›Primary plan

›Awake airway approach when feasible

›Fiberoptic intubation option when expertise available

›Backup plans

›Video laryngoscopy readiness with smaller tubes

›Supraglottic airway as rescue bridge only

›Surgical airway readiness

›If cannot intubate and cannot oxygenate, immediate cricothyrotomy

›ENT for tracheostomy consideration when time allows

Hemodynamic and sepsis considerations

›Shock and sepsis framework

›Septic physiology triggers

02History/hx46

Presentation pattern

›Symptom onset and tempo

›Rapid progression over hours

›Sudden severe sore throat

›Rapidly worsening dysphagia

›Prodrome variability

›Viral prodrome possible in adults

›Abrupt high fever more typical in bacterial cases

Key symptoms

›Upper airway obstruction symptoms

›Stridor

›Inspiratory stridor

›Stridor at rest as severe marker

›Drooling

›Inability to handle secretions

›Spitting secretions

›Voice change

›Muffled hot potato voice

›Weak voice

›Dyspnea

›Orthopnea

›Tripod posture

›Pain dominant symptoms

›Odynophagia

›Severe pain out of proportion to oropharyngeal exam

›Dysphagia

›Solid then liquid intolerance

03Physical Exam/exam38

General and airway appearance

›Work of breathing and posture

›Tripod or sniffing posture

›Leaning forward

›Neck extension

›Accessory muscle use

›Suprasternal retractions

›Tachypnea

›Voice and secretion control

›Muffled voice

›Inability to phonate normally

›Quiet voice due to pain

›Drooling

›Pooling secretions

›Frequent spitting

Vital signs and perfusion

›Physiologic severity markers

›Fever

›High temperature supports bacterial cause

›Tachycardia

›Pain and fever contribution

›Hypotension

›Sepsis concern

Head and neck exam

›Oropharynx and neck findings

›Minimal oropharyngeal findings

›Normal appearing tonsils despite severe pain

›Neck tenderness

04Differential Diagnosis/ddx35

Life threatening mimics

›Immediate life threats

›Anaphylaxis and angioedema

›Urticaria or lip tongue swelling

›Rapid swelling after exposure

›Foreign body aspiration

›Sudden onset choking

›Unilateral wheeze or air trapping

›Retropharyngeal abscess

›Neck stiffness

›Limited neck extension

›Ludwig angina

›Floor of mouth swelling

›Dental source

›Bacterial tracheitis

›Toxic appearance

›Thick secretions

Common upper airway conditions

›Infectious upper airway diagnoses

›Croup

›Barky cough

›Viral prodrome

›Peritonsillar abscess

›Uvular deviation

›Trismus

›Tonsillitis and pharyngitis

›Exudates

›Tender anterior cervical nodes

05Laboratory Tests/lt31

Core labs in moderate to severe presentations

›Infection and physiology labs

›Complete blood count for bacterial infection support

›Leukocytosis supportive but nonspecific

›Normal CBC does not exclude

›Basic metabolic panel for dehydration and renal function

›Renal function for antibiotic dosing

›Electrolyte derangements from poor intake

›Venous blood gas for ventilation concern

›Rising CO2 as impending failure marker

›Acidosis as severity marker

›Serum lactate for sepsis physiology

›Elevated lactate supports hypoperfusion

›Trend response to resuscitation

Microbiology

›Culture strategy

›Blood cultures in toxic or febrile or immunocompromised

›Two sets prior to antibiotics when feasible

›Do not delay antibiotics for cultures

›Epiglottic culture

›If secured airway and visualization in controlled setting

›OR or ICU setting preferred

Point of care testing

›Bedside tests

›Glucose in altered mental status

›Hypoglycemia exclusion

›Hyperglycemia in diabetes and sepsis

›Pregnancy test when relevant

06Diagnostic Tests/dt45

Scoring Systems

›Airway risk stratification tools

›Airway difficulty predictors

›Limited mouth opening and neck mobility

›History of difficult intubation

›Pediatric respiratory distress severity concepts

›Stridor at rest

›Retractions and agitation

›Clinical decision principle

›If signs of impending obstruction, prioritize airway control over diagnostic confirmation

MRI

›MRI role

›Limited acute utility

›Time and sedation requirements

›Not first line in unstable airway

›Deep neck space complication evaluation when stable

›Abscess extension assessment

›Soft tissue characterization

CT

›CT neck with IV contrast

›Indications in stable airway

›Uncertain diagnosis after clinical evaluation

›Suspected deep neck infection complication

›Contraindications and cautions

›Unstable airway or inability to lie flat

›Transport risk without airway control

›Key CT findings

›Enlarged edematous epiglottis and aryepiglottic folds

07Disposition/dispo32

Level of care

›Admission standards

›ICU level monitoring

›Any stridor at rest

›Any drooling or inability to swallow

›Any oxygen requirement

›Stepdown or ward criteria

›Mild symptoms with stable airway after specialist evaluation

›Rapid access to airway rescue resources

Airway secured pathway

›Post intubation disposition

›ICU admission

›Ventilator management and sedation

›Extubation planning with ENT and anesthesia

›Repeat airway assessment plan

›Cuff leak assessment considerations

›Endoscopic reassessment considerations

Transfer criteria

›Higher level of care transfer

›No ENT or anesthesia airway capability onsite

›Stabilize airway before transfer when feasible

›Critical care transport requirements

›Pediatric center transfer needs

›Pediatric anesthesia and ICU availability

›Pediatric ENT availability

Discharge rare pathway

›Discharge only when low risk after specialist evaluation

›No stridor

08Treatment/t77

Airway and respiratory support

›Airway management framework

›Noninvasive measures while preparing airway

›Humidified oxygen

›Upright positioning

›Intubation approach

›Awake fiberoptic technique when feasible

›Small endotracheal tube selection

›0.5 to 1.0 mm smaller internal diameter than age based estimate in children

›Backup tube sizes available

›Rescue oxygenation

›Bag mask ventilation readiness

›Supraglottic airway as temporary rescue

›Surgical airway

›If cannot intubate and cannot oxygenate, immediate cricothyrotomy

›ENT tracheostomy if time and anatomy permit

Antibiotics

›Empiric antimicrobial coverage

›Target organisms

›Haemophilus influenzae

›Streptococcus species

›Staphylococcus aureus including MRSA risk groups

›First line regimens

›Ceftriaxone IV 2 g daily adult

›Pediatric ceftriaxone IV 50 mg/kg daily

›Maximum 2 g daily

›Cefotaxime IV 2 g every 6 to 8 hours adult

›Pediatric cefotaxime IV 50 mg/kg every 6 hours

›Maximum per local pediatric dosing limits

›MRSA coverage when indicated

›Vancomycin IV weight based dosing per local protocol

›Therapeutic drug monitoring plan

›Renal dosing adjustments

›Clindamycin IV 600 to 900 mg every 8 hours adult as alternative

›Pediatric clindamycin IV 10 mg/kg every 8 hours

›Maximum 900 mg per dose

›Beta lactam allergy options

›Levofloxacin IV 750 mg daily adult

›Pediatric fluoroquinolone use only with specialist input

›Tendinopathy and QT risk counseling considerations

Steroids and adjuncts

›Anti-inflammatory therapy

›Dexamethasone IV 10 mg adult

›Pediatric dexamethasone IV 0.6 mg/kg

›Maximum 10 mg

›Evidence framing

›Steroids commonly used to reduce airway edema

›Benefit signal mainly from observational practice patterns

›Nebulized therapies

›Racemic epinephrine as bridge in severe stridor

›Use only with airway team immediately available

›Rebound monitoring requirement

›Heliox as temporizing measure

›Consider when severe obstruction and awaiting definitive airway

›Requires appropriate delivery system

Supportive care

›Analgesia and antipyresis

›Acetaminophen dosing per weight

›Avoid oversedation

›Improve cooperation and reduce distress

›Opioids only with airway oversight

›Risk of hypoventilation

›Prefer titrated small doses if required

›Fluids and nutrition

›IV fluids for poor intake

›Dehydration correction

›Maintenance fluids while NPO

›NPO until airway stable

›Aspiration risk

›Planned airway procedures

Post exposure prophylaxis

›Hib household and close contact prophylaxis

›Rifampin prophylaxis pathway when Hib confirmed or strongly suspected

›Public health notification process

›Immunization status review for contacts

Evidence levels and guideline style notes

›Recommendation strength framework

›Class I style recommendation for early airway team involvement in impending obstruction

›Supported by airway safety consensus

›Time critical risk mitigation

›Class IIa style recommendation for third generation cephalosporin empiric therapy

›Broad pathogen coverage

›Favorable safety profile

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Physiologic airway changes

›Increased mucosal edema

›Reduced functional residual capacity

›Medication considerations

›Beta lactams and cephalosporins generally acceptable

›Avoid unnecessary sedatives

›Imaging considerations

›Prefer bedside and clinical diagnosis when possible

›If CT necessary, shielding and risk benefit framing

Geriatric

›Older adult considerations

›Atypical presentations

›Less fever

›Pain dominant complaints without overt distress early

›Comorbidity risks

›Diabetes and immunosuppression

›Higher risk sepsis and complications

›Medication safety

›Renal dosing for antibiotics

›Delirium risk with sedatives

Pediatrics

›Pediatric specific approach

›High agitation risk

›Caregiver presence

›Minimal interventions until airway plan ready

›Airway planning

10Background/b34

Epidemiology

›Population patterns

›Hib vaccine era shift

›Reduced pediatric Hib epiglottitis incidence

›Adult cases remain clinically important

›Common pathogen spectrum

›Haemophilus influenzae

›Streptococcus species

›Staphylococcus aureus

›Risk group enrichment

›Diabetes

›Immunocompromise

Pathophysiology

›Mechanism and anatomy

›Supraglottic infection and inflammation

›Epiglottic edema

›Aryepiglottic fold edema

›Airway obstruction physiology

›Rapid luminal narrowing

›Dynamic collapse with negative inspiratory pressure

›Complication pathways

›Abscess formation

›Bacteremia and sepsis

Therapeutic Considerations

›Why therapies work

›Airway first principle

›Obstruction can progress abruptly

›Definitive airway prevents sudden arrest

11Patient Discharge Instructions/pdi17

copy discharge instructions

›Discharge instructions for rare outpatient pathway

›Medication adherence

›Complete full antibiotic course if prescribed

›Avoid missed doses

›Hydration and diet

›Frequent small sips of fluids

›Soft foods as tolerated

›Return to ER immediately

›Any breathing difficulty

›Any stridor or noisy breathing

›Drooling or inability to swallow

›Worsening throat pain

›Voice change

›Fever persistence beyond 48 hours on antibiotics

›Follow up

›ENT or primary care reassessment within 24 hours

›Immunization review for Hib if not up to date

12References/r13

Clinical guidelines and evidence sources

›Reference set

›Pediatric airway and epiglottitis management consensus statements

›Emphasis on minimal agitation and controlled airway environment

›OR capable setting for unstable pediatric airway

›Infectious disease guidance on upper airway bacterial infections

›Third generation cephalosporin empiric therapy

›MRSA coverage by risk and local patterns

›Public health guidance for Hib exposure management

›Rifampin prophylaxis for close contacts when indicated

›Immunization catch up principles

Internal specification source

›Source file citations

›Clinical management system generator specification

›Checkbox nesting and subsection container requirements applied

Evidence & Review

Evidence & Review