A 3-year-old child presents with stridor and drooling. He is diagnosed with epiglottitis.
What is the most appropriate immediate management?
Correct Answer A: Epiglottitis is a rapidly progressive bacterial infection of the epiglottis and surrounding tissues that may lead to sudden respiratory obstruction and death. Symptoms include severe sore throat, dysphagia, high fever, drooling, and inspiratory stridor. Diagnosis requires direct visualization of the supraglottic structures, which is not to be performed until full respiratory support is available.
In children, the airway must be secured immediately, preferably by nasotracheal intubation. An endotracheal tube is usually required until the patient has been stabilized for 24 to 48 h (usual total intubation time is < 60 h).
A beta-lactamase resistant antibiotic, such as ceftriaxone should be used empirically, pending culture and sensitivity test results. Epiglottitis is caused by H. influenzae type B can be effectively prevented with the H. influenzae type B (Hib) conjugate vaccine.
A healthy 4-year-old girl presents with the following symptoms: rapidly progressing respiratory distress, high fever, muffled voice, and drooling. Which one of the following measures is most appropriate in the initial management of this problem?
Correct Answer A: Epiglottitis is a rapidly progressive bacterial infection of the epiglottis and surrounding tissues that may lead to sudden respiratory obstruction and death. Symptoms include severe sore throat, dysphagia, high fever, drooling, and inspiratory stridor.
Diagnosis requires direct visualization of the supraglottic structures, which is not to be performed until full respiratory support is available. Treatment includes prompt airway protection via intubation and antibiotics.
A child is brought to the emergency department. He has a temperature of 39.4°C and respiratory distress. He is leaning forward and has a very anxious look. His voice is muffled, and he is unable to swallow. X-ray shows a swollen epiglottis.
Proper treatment at this time would include all of the following, except:
Correct Answer B: Children with epiglottitis should be allowed to sit and lean forward to help their airways open (choice B is the correct answer). All of these signs and symptoms are typical. As these children may obstruct totally at any time, rapid preparations must be made to maintain an airway.
→ The first emergency department priority for a patient with epiglottitis is securing and providing respiratory support before a definitive airway is obtained. Initially, humidified oxygen (choice A) can be given by a nasal cannula or a nonrebreather mask, as required.
→ Reassurance and allowing the mother to hold the child (choice C) will decrease distress while you arrange proper treatment.
→ This child should be evaluated in a controlled setting (i.e., in an operating room in the presence of an anesthesiologist and/or otolaryngologist) (choice D) so that rapid airway control may be achieved, if necessary.
→ Sudden pulmonary arrest (choice E) is a likely occurrence in children with epiglottitis and should be anticipated.
Non-bilious projectile vomiting occurs in which of the following condition?
Correct Answer A: Hypertrophic pyloric stenosis can cause almost complete gastric outlet obstruction.
Symptoms develop between 2 and 6 weeks of life. Projectile vomiting (without bile) occurs shortly after eating. Until dehydration sets in, the child feeds avidly and otherwise appears well, unlike many of those with vomiting due to systemic illness.
Diagnosis is by abdominal ultrasonography showing increased thickness of the pylorus (typically to ≥ 4 mm; normal, < 2 mm). The classic electrolyte pattern of an infant with pyloric stenosis is that of hypochloremic, hypokalemic, metabolic alkalosis.
Initial treatment is directed at hydration and correcting electrolyte abnormalities. Definitive treatment is a longitudinal pyloromyotomy, which leaves the mucosa intact and separates the incised muscle fibers.
All of the following are present in pyloric stenosis, except:
Correct Answer D: Hypertrophic pyloric stenosis is obstruction of the pyloric lumen due to pyloric muscular hypertrophy. It is more common in males by a 4:1 ratio.
Projectile vomiting (without bile) occurs shortly after eating. Until dehydration sets in, the child feeds avidly and otherwise appears well, unlike many of those with vomiting due to systemic illness. Gastric peristaltic waves may be visible, crossing the epigastrium from left to right. An enlarged pylorus (firm, movable mass), classically described as an "olive," can be palpated in the right upper quadrant or epigastrium of the abdomen in 60-80% of infants.
The classic electrolyte pattern of an infant with pyloric stenosis is that of hypochloremic, hypokalemic, metabolic alkalosis.
→ The hallmark physical findings in intussusception are a right hypochondrium sausage shaped mass and emptiness in the right lower quadrant (Dance sign).
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