This is the protocol for Epiglottitis:epiglottitis
Let’s break it down!
If you don’t remember what your epiglottis is, it’s the flappy “leaf-like structure” in the back of your throat that keeps food from entering your trachea when you’re eating. Naturally, this is a pretty important structure. Epiglottitis occurs when the epiglottis becomes infected and inflamed, potentially causing life-threatening airway obstruction.
Luckily for us, epiglottitis is not nearly as common as what it used to be. Historically, most cases of epiglottitis only affected children under the age of 5 and it was predominantly caused by H. influenza type B. But since the widespread adoption of Hib vaccinations, the incidence of epiglottitis has decreased by more than 90%.
Still, epiglottitis is not completely gone. In the post-Hib-vaccine era, Streptococcus and Staphylococcus are now the leading causes of epiglottitis. In addition, other things like trauma and inhalation injuries can still cause it as well. The average age of patients with epiglottitis is 45. For a more in-depth review, check out the video below:
When you look at a picture of a normal epiglottis vs an infected one, it’s easy to identify a case of epiglottitis:
But of course, we’re not going to actually be able to physically see a case of epiglottitis with the limited equipment we have. At best, you’ll see an erythematous (red) pharynx, which is something that you might find with any upper respiratory infection. So how can we tell the difference between epiglottitis and something like strep throat?
For starters, cases of epiglottitis are MUCH more severe. It may start as a strep throat infection at first, but epiglottitis in and of itself comes on very fast and the first thing that you’ll probably notice is how anxious the patient is (because they can barely breathe!) Next, you may notice that they are drooling. The inflammation and pain from epiglottitis often prevent patients from being able to swallow appropriately, thus leading to an overflow of saliva. Also, they will have difficulty speaking.
1. Place patient in sitting or comfortable position
Any conscious patient struggling to breathe should always be allowed to control their airway. They know exactly what position is best for them. Typically, it’ll be a sitting tripod position. As mentioned earlier, the inflammation in the back of their throat often prevents them from being able to swallow and clear out the build-up of saliva. A supine position would almost certainly make it that much more difficult for them to breathe.
2. IV access, pulse oximetry, and O2 if available
IV access will be necessary for the rapid absorption of proper medications. Pulse oximetry is crucial for determining the severity of the epiglottitis and helping you gauge when aggressive airway interventions need to be applied. O2, of course, will help oxygenate the patient while other treatments are being prepared.
Powerful broad-spectrum antibiotics like Ceftriaxone and Amoxicillin/clavulanic acid are essential for the rapid elimination of bacteria causing epiglottitis. Generally speaking, ceftriaxone is preferred over Amoxicillin/clavulanic acid simply because it may be difficult for the patient to swallow any PO medications.
The use of steroids like Dexamethasone is controversial in cases of epiglottitis, but the idea is that the steroids would help reduce the inflammation of the epiglottis and aid in recovery. It’s not quite certain how effective this is, but I would still use it in severe cases.
5. Do not manipulate airway unless required, let the patient protect his own airway
In cases of epiglottitis, we have to be particularly careful not to disturb the epiglottis. Poking around with a suction tip or an endotracheal tube has the potential to further exacerbate the inflammation and take away what little airway they have left. Allowing the patient to manage his/her airway is good enough for approximately 80% of patients.
6. If definitive airway is needed, make one attempt at intubation. If failed, perform a cricothyroidotomy.
16% of patients require intubation and 3% of patients require a surgical airway. Determining the need for a definitive airway is tricky; it mostly relies on clinical judgment. A patient with poor O2 saturation and a diminished mental status would probably be your best candidate. Understand, however, that these interventions for epiglottitis are probably best performed by clinicians beyond our combat medic scope.
The majority of patients with acute epiglottitis typically recover without residual airway or other problems if the airway is promptly secured and appropriate antimicrobial therapy is administered. However, due to the risk of a rapid airway obstruction, an Urgent evacuation is always warranted in our setting. These patients will require very close attention over the next several days to ensure that their condition does not worsen.
Good luck out there!
- Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol. 2008;122(8):818–823. doi:10.1017/S0022215107000473
- World Health Organization (September 2013). “Haemophilus influenzae type b (Hib) Vaccination Position Paper — July 2013”. Weekly Epidemiological Record. 88 (39): 413–26. hdl:10665/242126
- EMRAP Corependium: Pharynx and Throat Emergencies
- UpToDateL Epiglottitis (Supraglottitis) Management
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.