A 3-year-old boy is brought to A&E with his mother as she is concerned he has not been eating since the morning. She says she has heard him making strange breathing noises which she cannot explain. He has not had all of his childhood vaccines, but his past medical history is otherwise unremarkable. On examination, he is sitting upright with his mouth open and drooling, and there is evidence of inspiratory stridor. He is crying out in pain and has a muffled voice when he tries to talk. He is unable to eat and drink. His vital signs show HR 160bpm, 45 breaths per minute, a systolic BP of 70mmHg, and temperature of 39.9.

Which of the following is the most appropriate next step in his  management?

Options:
explanation: This child has acute epiglottis, which is often caused by Haemophilus influenzae type B. Fortunately, due to vaccinations, this is becoming less common, but this child has not had all of his childhood vaccinations. He has evidence of airway obstruction, and so the immediate next step is to secure his airway. Any further delay may result in complete airway obstruction. It is important to do nothing to cause additional distress, including cannulation or further examination, since this may result in further emotional distress and sudden loss of the airway.
name: Call the anaesthetists for intubation and ventilation
label: a
answer: yes
explanation: This is incorrect because intramuscular adrenaline is a treatment for  anaphylaxis. This is an important differential diagnosis because anaphylaxis causes shortness of breath and stridor. However, one would expect additional clinical features, such as acute onset, rash, itch, and onset after exposure to an allergic trigger. However, this patient does not have anaphylaxis, and the priority in any case in the context of apparent airway obstruction is to secure his airway.
name: Intramuscular adrenaline
label: c
answer: no
explanation: Oral dexamethasone is provided for children with croup, which is caused by Parainfluenza virus. Croup is an important differential diagnosis for acute epiglottitis because it can present with stridor, but the child is well and able to eat and drink (though may be off food.) Fevers are usually low-grade, and the child has a characteristic barking cough. Drooling is not a feature.
name: Oral dexamethasone
label: d
answer: no
explanation: This child has acute epiglottis, which is often caused by Haemophilus influenzae type B. Fortunately, due to vaccinations, this is becoming less common, but this child has not had all of his childhood vaccinations. He has evidence of airway obstruction, and so the immediate next step is to secure his airway. Any further delay may result in complete airway obstruction. It is important to do nothing to cause additional distress since this may result in sudden loss of the airway. Applying a nebuliser mask to this clearly upset, crying child who is in pain may cause further distress which can precipitate acute airway obstruction, and furthermore delay the most important next step, which is to prioritise securing the airway at this stage.
name: Nebulised adrenaline
label: e
answer: no
explanation: This child has acute epiglottis, which is often caused by Haemophilus influenzae type B. Fortunately, due to vaccinations, this is becoming less common, but this child has not had all of his childhood vaccinations. He has evidence of airway obstruction, and so the immediate next step is to secure his airway. Any further delay may result in complete airway obstruction. It is important to do nothing to cause additional distress, including cannulation for intravenous antibiotic administration, or further examination, since this may result in further emotional distress, airway spasm, and sudden loss of the airway. Intravenous antibiotics can be provided once the airway is secured.
name: Intravenous antibiotics
label: b
answer: no

Correct answer: a


Learning point: The management of acute epiglottitis involves immediate securing of the airway, often through endotracheal intubation or, in severe cases, a tracheostomy, along with administration of antibiotics to treat the underlying infection and corticosteroids to reduce inflammation.