# epiglotittis treatment for the BLS staff...



## yotam (Dec 18, 2010)

Hello all,

In epiglotittis, we learned that *any* contact with the mouth is dangerous for the patient, on the other hand the most immediate treatment should be airway treatment. What is the correct approach for this patient in the BLS level?


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## adamjh3 (Dec 18, 2010)

Dangerous how?

Airway is one of, if not the highest priority. If your patient isn't breathing, whatever you do for anything else won't matter.


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## yotam (Dec 18, 2010)

*As far as I was taught...*

In the first stage the airway is highly sensitive to any trauma, even the mildest blow to the neck could triger the reaction. In the stages before full closure of the trachea (in which case I will obviously intervene with every measure I have), could invoke the pathological reaction, and therefore the caregiver  should avoid any contact with the area. 

Again, I've never actually seen such patient, and this is merely what I was taught. I'm addressing this thread to anybody who has attended a patient with epiglotittis and could share some tips (Even if they include debunking what I was taughth34r.


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## CAOX3 (Dec 18, 2010)

In epiglottitis the airway needs aggressive attention either intubation or late stages a surgical or needle cric, these kids are sick, you could see tripoding, drooling, extreme agitation.

No ****ing around here get them to the hospital or snow them and intubate sooner then later , if their airway closes their done unless you have crics in you r bag of tricks.  At the bls level your job is to get them als as soon as possible,  try to keep them calm, sit them up and try not to aggrevate the situation at all, you won't be able to bag them once their closed, these kids don't trick you, you will know as soon as you hit the door that these kids need immediate medical attention.

There really is no treatment in the field besides aggressive airway management. It can be caused by trauma but usually its infection, its treated with antibiotics.  With kids this is truly a race against time its not if but when their going to close up on you if you encounter it with an adult you may have some time but don't bet on it.


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## yotam (Dec 18, 2010)

*Thank you...*

It's pretty much what I was taught, but you sharpened it for me. Have you ever seen such a patient? what should I expect? (especially in children where the infection is much more dangerous).


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## CAOX3 (Dec 18, 2010)

I have seen a few, one thing is these kids look sick.  I don't know what you're protocols include,  humidified o2,  epi neb may buy you some time, but its best if these kids conditions are addressed by someone who had the ability to place an airway.  Don't sit on them, don't minimize their symptoms, they will die on you.  Thorough assessment is imperative, epiglottitis can mimic other airway problems, croup and such, in my experience you don't get the barky cough usually, may be some stridor, but the key is the onset and the presence of a temp, maybe they complained of a sore throat or they didn't eat much that day, the parents can be very helpful in ruling them in for epiglotit tis.

The main thing is recognition these kids are sick and are going to die without an airway.  Your really on the clock with these kids.  You can't be passive with them their going to need aggressive airway management so get them a paramedic or a hospital pronto.  I'm not positive and maybe some more educated and experienced providers will chime in but in my experience this is what your up against.


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## CAOX3 (Dec 18, 2010)

adamjh3 said:


> Dangerous how?
> 
> Airway is one of, if not the highest priority. If your patient isn't breathing, whatever you do for anything else won't matter.



Because epiglottitis is a swelling problem so screwing around in there will just exacerbate the problem, when this kids airway slams shut your up the creek with out a paddle unless your medics can cric.

You cant bag these kids, the the epiglottis swells over the trachea and if its severe you wont be able to intubate them either.

So if you suspect it, leave their airway alone, keep them calm and get someone or somewhere that can address the airway permanently.


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## WTEngel (Dec 18, 2010)

Yes these kids are extremely sick, and need treatment urgently. Being able to hear stridor is a good sign believe it or not, because as the stridor gets quieter, this means the airway is getting more constricted.

From a BLS standpoint, cooled humidified o2 is good, unless it agitated the patient, in which case take whatever measures are necessary to not cause any duress, as this will exacerbate the issue.

It really all depends on what your transport times are. If you find the patient stridorous and tripoding and you have a 10 minute transport time, I would say supportive care and very rapid transport. If you have a longer transport time, you will need to assess very carefully what you want to do.

ANY agitation to these kids is bad. Unless it is absolutely necessary, I would be cautious about starting an IV unless you are fully prepared to intubate. You have one chance to intubate these patients, and sometimes you don't even have that chance. In fact even in the pediatric ER I used to work in (one of the largest level one trauma centers in the US) and on our critical care transport team, intubation of these patients was limited to the OR and anesthesiologist at all costs, unless completey unavoidable.

The reason I am writing all of this is to make this point... Be careful of jumping all the way in and snowing a kid who has an airway, even if it isn't ideal. You have a nearly 100% chance of missing this intubation, and surgical crocs and trachs are more easily said than done, especially in peds with inflamed upper airway anatomy.

Obviously if the child's airway is fully obstructed, all bets are off and you need to take all measures necessary to ventilate the child.


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## MrBrown (Dec 19, 2010)

Call for an RSI qualified Intensive Care Paramedic or Doctor (like Brown!) with much of the fastness 

*Note:* Brown may or may not be an RSI qualified ICP and/or Doctor


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## mycrofft (Dec 19, 2010)

*Tincture of "hurryup", but don't jostle em.*

If you're work too far out from hospitals, get some paramedics trained and hired.


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## TransportJockey (Dec 19, 2010)

This is one of the patients that the best treatment, even for ALS is a massive diesel bolus.


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## yotam (Dec 19, 2010)

*Will do...*

No stay & play, rapid transportation, don't touch facial area unless needed, call doctor Brown. G'otcha. thank you all, hope I won't need your help.


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## Shishkabob (Dec 19, 2010)

When it comes to eppiglotitis, you'll do what ALS does--- transport to the hospital safely, quickly, and without aggravating the demon-leaf.  

We don't even RSI as that could end up shutting it off too.  We'll have our cric kit ready, but that's about the only difference between ALS and BLS.


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## NomadicMedic (Dec 19, 2010)

Linuss said:


> When it comes to eppiglotitis, you'll do what ALS does--- transport to the hospital safely, quickly, and without aggravating the demon-leaf.
> 
> We don't even RSI as that could end up shutting it off too.  We'll have our cric kit ready, but that's about the only difference between ALS and BLS.



+1. Don't mess about. Drive expeditiously to the nearest (appropriate) hospital. 

I spoke with a medical control doc about this last night after reading the post and he told me that nebulized Epi may return in one of the county's next protocol revisions.


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## Shishkabob (Dec 19, 2010)

n7lxi said:


> +1. Don't mess about. Drive expeditiously to the nearest (appropriate) hospital.
> 
> I spoke with a medical control doc about this last night after reading the post and he told me that nebulized Epi may return in one of the county's next protocol revisions.



We have nebulized epi, but only for croup.  If we can't decide between croup or epiglottis, we treat it as epiglottis and transport.


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## Simusid (Dec 19, 2010)

A related question:   A sign of epiglottitis is stridor, inspiratory wheezes in the upper airway.   I was always taught that, but I never thought to ask..... if I hear stridor in the upper airway, what might I hear in the lower airway?  will I hear the same wheezes?


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## Shishkabob (Dec 19, 2010)

You might hear the resonance in the lungs, much the same way as you'll hear the resonance of someone talking while listening to the lungs.


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## WTEngel (Dec 19, 2010)

I am not advocating anyone change their protocols or giving any medical advice, but we trailed nebulized epi 1:1000 in epiglottitis cases with positive results. Worked better than the racemic, which we still reserved for ...


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## TransportJockey (Dec 19, 2010)

WTEngel said:


> I am not advocating anyone change their protocols or giving any medical advice, but we trailed nebulized epi 1:1000 in epiglottitis cases with positive results. Worked better than the racemic, which we still reserved for ...



I have standing orders for neb epi for croup and epiglotittis. Mainly for when we're out in the county, but we can do it even in town if needed.


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## WTEngel (Dec 19, 2010)

Do you carry racemic or are you using 1:1000?


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## WTEngel (Dec 19, 2010)

Also, for whatever reason the last word was cut off in my post above, basically I was saying we were using epi 1:1000 for epiglottitis and racemic for croup, respectively.

Racemic epi will do wonders for your croupers, if you can get past the point where they are coming unglued because you are giving them a neb treatment. That's the catch 22 with these URIs is that most interventions only make the problem worse in the immediate sense, until they have had time to take effect...so these kids almost always get worse before they get better.


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## TransportJockey (Dec 19, 2010)

WTEngel said:


> Do you carry racemic or are you using 1:1000?



1:1000 only... Never seen it used for either yet though. Then again I don't htink I've seen a single pedi since I started working down here


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## CAOX3 (Dec 19, 2010)

We carry 1:000 nebs, and had racemic up until about two years ago at the bls level.

Ive used racemic a few times with marked improvement in croupy kids, they replaced it with 1:000 for all upper airway distress wich I haven't used as of yet.  I believe the racemic was removed due to the rebound effects and the admission status, I don't know if that's changed but we don't carry it anymore.

I wasn't that keen on using it at first because the education wasn't really there, as I studied it more I got more comfortable with administering it, but I still would usually get a doc on the phone just to run the presentation by him first.


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## CodyHolt83 (Dec 20, 2010)

I was interested in the Epiglottitis section of EMT as well.  Is sounds like the best treatment is high-flow O2, position of comfort, rapid transport, and try not to make the pt talk at all.  I have never even heard about it, but it was an interesting topic to me.  I guess I'll go google it now.


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## CAOX3 (Dec 20, 2010)

Humidified is going to be your best bet if you have that available


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## TransportJockey (Dec 20, 2010)

CAOX3 said:


> Humidified is going to be your best bet if you have that available



humidified is easy. Mask + SVN + Normal saline from an IV bag.


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## usalsfyre (Dec 20, 2010)

The LAST thing I'm going to do is touch this kid's airway, as long as he is doing a somewhat decent job of maintaing it. Absent signs of hypoxia, we're not even going to bother him with O2. Just a nice, quiet, easy ride to an ED that can deal with an airway disaster if it should happen. I am going to have every airway tool available to me out and ready, up to and including a cric. 

Luckily for parents and EMS, kids are vaccinated against the most common causative organisims for epiglotitis.


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## TransportJockey (Dec 20, 2010)

usalsfyre said:


> The LAST thing I'm going to do is touch this kid's airway, as long as he is doing a somewhat decent job of maintaing it. Absent signs of hypoxia, we're not even going to bother him with O2. Just a nice, quiet, easy ride to an ED that can deal with an airway disaster if it should happen. I am going to have every airway tool available to me out and ready, up to and including a cric.
> 
> Luckily for parents and EMS, kids are vaccinated against the most common causative organisims for epiglotitis.



SHould be vaccinated. I know of a couple hippy parents that I've run done emergent IFT for their kids with epiglotitis because they didn't believe in shots.


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## Veneficus (Dec 20, 2010)

jtpaintball70 said:


> SHould be vaccinated. I know of a couple hippy parents that I've run done emergent IFT for their kids with epiglotitis because they didn't believe in shots.



This is actually becomming more common in all places around the globe. 

Because of negative publicity and a lot of people who don't know as much as they think they do about medicine, the "no vaccination" campaigns are gaining traction.

I guess you could call it a very cruel for of natural selection.


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## WTEngel (Dec 20, 2010)

You know what I found interesting when I was working in the pediatric world...the kids who werent vaccinated would for the most part end up vaccinated by proxy. Because 95% of the children around them were vaccinated against the common diseases, they would not contract them, therefore the children could not transmit them. With such a small pool of children who could transmit the diseases, there wasn't a very high occurrence of them getting sick.

Now, the real scary part was if these kids did happen to be exposed, they got incredibly sick. There was also a higher incidence of them having issues later into their teens and adulthood.

It always fascinated me how these parents would react to you asking about their child's immunization status during the triage process versus in the social setting. In the social setting around friends and peers, they would act almost smug or high and mighty about their decision. During the triage process or when dealing with medical personnel, they acted almost embarassed.

Just thought this was interesting to point out...


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## uhbt420 (Dec 20, 2010)

keep the child calm and call ALS.  if no ALS, get to the hospital ASAP.  yesterday, if possible.

i had the misfortune of having one of these pts a few months ago.  my partner thought it was croup and figured it was a good idea to check the mouth and palpate the trachea.  fire department had to cric the kid after that.


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## WTEngel (Dec 20, 2010)

Even if it was croup messing with the trachea and doing anything to the airway that was not absolutely necessary was a bad idea.

Do not mess with these kids. They get angry, and then can not breathe.


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## Aidey (Dec 20, 2010)

WTEngel said:


> You know what I found interesting when I was working in the pediatric world...the kids who werent vaccinated would for the most part end up vaccinated by proxy. Because 95% of the children around them were vaccinated against the common diseases, they would not contract them, therefore the children could not transmit them. With such a small pool of children who could transmit the diseases, there wasn't a very high occurrence of them getting sick.



Herd immunity


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