Epiglottitis

-       Epiglottitis is an acute inflammation of the epiglottis and other supraglottic structures that can lead to airway obstruction -       Is a true airway emergency

-       Haemophilus influenzae used to be the most common pathogen prior to the development of the Hib vaccine. Now, common pathogens include Streptococcus pneumoniae, Staphylococcus aureus, and beta-hemolytic streptococci.

-       Due to immunizations against Haemophilus influenzae serotype b, epiglottitis has decreased in the pediatric population and is now more commonly seen between 30-50 years of age

-       The most common chief complaint is Sore throat

Physical Exam

-       Toxic-appearing, febrile, tachypneic, tachycardic, inspiratory stridor, muffled voice, drooling, anterior neck tenderness (hyoid bone)

Imaging

-       Laryngoscopy is the most accurate method to establish the diagnosis

-       Lateral soft-tissue radiograph of the neck is 88% sensitive. Image findings include a swollen epiglottis termed “thumb sign”. Absence of the “thumb sign” does not exclude the diagnosis

Evaluation and Management

-       Diagnosis is clinical and confirmed with laryngoscopy.

-       Early ENT consultation

-       Patient should remain in a position of comfort. Avoid agitation as it may precipitate airway obstruction

-       If respiratory distress or stridor is present, prepare for intubation.

-       Intubation should be performed in the OR if the patient is stable for transport. For unstable patients, awake fiberoptic intubation is recommended with an anesthesiologist present at bedside.Intubation should be attempted by the most experienced physician.

-       If intubation is unsuccessful, perform emergent cricothyroidotomy

-       Antibiotics: Ceftriaxone (50 mg/kg up to 2 grams IV) and vancomycin (15 mg/kg for concern for MRSA) are a good choice. Trimethoprim- sulfamethoxazole is an acceptable alternative for patients with PCN allergy

-       Decadron (0.1 mg/kg up to 10 mg IV).

-       Disposition: ICU.

Sources:

EM docs, FOAM EM RSS

Wellens' syndrome

Definition:

• Wellens’ syndrome is a pattern of deeply inverted or biphasic T waves in V2-3, which is highly specific for a critical stenosis of the left anterior descending artery (LAD)
• There are two patterns of T-wave abnormality in Wellens’ syndrome:
  • Type A = Biphasic, with initial positivity & terminal negativity (25% of cases)
  • Type B = Deeply and symmetrically inverted (75% of cases)

What happens exactly?

1. Sudden occlusion of the LAD, causing a transient anterior STEMI. The patient has chest pain & diaphoresis.
2. Re-perfusion of the LAD (e.g. due to spontaneous clot lysis or prehospital aspirin). The chest pain resolves. ST elevation improves and T waves become biphasic or inverted.
3. If the artery remains open, the T waves evolve over time from biphasic to deeply inverted.
4. The LAD can re-occlude at any time. If this happens, the first sign on the ECG is an apparent normalisation of the T waves (“pseudo-normalisation”). The T waves switch from biphasic/inverted to upright.
5. If the artery remains occluded, the patient now develops an evolving anterior STEMI.

Diagnostic criteria:

• Deeply inverted or biphasic T waves in V2-3 (may extend to V1-6)
• Isoelectric or minimally-elevated ST segment (< 1mm)
• No precordial Q waves
• Preserved precordial R wave progression
• Recent history of angina
• ECG pattern present in pain-free state
• Normal or slightly elevated serum cardiac markers

Why is this important?

• Myocardial infarction occurs within a mean of 6 – 8.5 days after admission
•  Myocardial infarction occurs within a mean of 21.4 days after symptoms

Management:

• Oxygen, aspirin, nitroglycerin, and heparin are the mainstay medical treatments of unstable angina, which is what Wellens’ Syndrome is, but in this specific case early cardiac revascularization is very important!
• The treatment of choice to improve both morbidity and mortality in Wellens’ Syndrome is early PCI- these patients need to go to the cath lab!
• Stress testing is contraindicated since it can induce a massive anterior myocardial infarction

Sources:

Life in the Fastlane, R.E.B.E.L EM

Tongue Lacerations

Kids are gravitationally challenged and fall all the time! This often leads to simple bumps, bruises and minor injuries. Occasionally, kids present to the ED with tongue lacerations. -       The most common location is the anterior portion of the tongue.

-       Lacerations on the lateral side of the tongue are usually associated with seizures

-       When you find one laceration, always look for another.

Management:

-       Don’t get distracted by the obvious tongue injury.

-       It’s a trauma, so assess the airway

-       The airway can be compromised by:

o   Bleeding

o   Tongue swelling

o   Retained foreign bodies:

• Fragments of teeth
• Fragments of other objects

-       To Close or Not To Close?

o   Primary repair in the ED should be considered for tongue lacerations with the following characteristics:

• Bisect the tongue extending through the free edge – creating the “snake” look
• Have large mobile flaps or U-shaped defects (>1-2cm)
• Gaping at rest
• Won’t stop bleeding

Repair:

-       You’ll need to get everything together beforehand, and consider providing sedation. Local anesthesia can be provided with 4% lidocaine gel on gauze applied for 5 minutes, 1% lidocaine injected into the tongue, or an inferior alveolar nerve block which will block the lingual nerve and the anterior 2/3 of the tongue.

-       You also need to control the tongue and keep it protruded. This can be accomplished by grabbing the tip with forceps, or by placing a large (2-0 nylon) suture through the tip.

-       Copious irrigation without drowning the patient is important.

-      Length of the procedure is an issue for younger/sedated patients, but you also want the sutures to stay in place as they can become untied due to the normal movements of the tongue. Therefore, it is important to use absorbable sutures (4-0 chromic gut) and bury the knots in the tongue itself if possible.

-       The patient should be discharged on a soft diet for 2-3 days, and encouraged to do peroxide/chlorhexidine mouth rinses after eating. Specific follow-up is only necessary for poor healing wounds, or those that lead to problems with speech or eating. Antibiotics are not necessary.

Watch this short video showing a tongue laceration repair in a child under procedural sedation:

https://www.youtube.com/watch?v=6sbIrVIDzZk

Sources:

Pediatric EM morsels

PEMblog briefs