A: Airway = ABCDEFGHIJKLMNOP

upperairway

Emergency Medicine starts with the ABCs, and the “A” means two questions for every patient: 1) Apply c-collar (to protect cervical spine in the trauma patient)? and 2) Airway management?

For the second question we need to be aware of the conditions that can directly affect the airway. These should be considered in every patient with sore throat, cough, voice changes, shortness of breath, stridor, and facial swelling. Just remember your alphabet, which puts strep throat and viral pharyngitis at the end of the list so you don’t miss more important causes of airway problems: Anaphylaxia/Angioedema/Angina Ludwig/Abscess, Bacterial tracheitis, Croup, Diphtheria, Epiglottitis, Foreign body, Growth, Hematoma, Inhalation, Johnson-Steven, Kawasaki, Laryingitis, Mono, Node, O Antistreptolysin Pharyngitis

Anaphylaxis:

anaphylaxis

  • rapid allergic reaction after exposure an allerge, eg nuts, seafood, medications
  • clinical diagnosis involving at least two systems (airway, lungs, cardiovascular, GI, derm) in response to allergen
  • treatment: ABCDEFGH, with emphasis on early +/- repeated doses of adrenalin/epinephrine: Adrenalin IM, beta agonist (ventolin), corticosteroids, Decontamination (eg remove bee sting), Epi (repeat IM dose, or IV if refractory), Fluids, Glucagon if on beta-blocker, Histamine blocker

Angioedema

Angioedema

  • another life-threatening cause of upper airway obstruction of lips/tongue, based on clinical diagnosis
  • hereditary (C1 esterase deficiency), allergic, or drug-induced (ACE inhibitors)
  • treatment with C1 esterase (if hereditary), FFP, trial epi/steroids +/- intubation

Angina Ludwig

ludwig

  • potentially life-threatening cellulitis of the floor of the mouth after an odontogenic infection
  • treatment with antibiotics, urgent ENT consult, prepare for difficult airway

Abscess: submandibular, peritonsillar, retropharyngeal

peritonsillar

  • oral infectious causing abscesses that can cause obstruction and sepsis
  • submandibular visible/palpable below mandible; peritonsillar visible in oropharynx; retropharyngeal on soft tissue Xray of children

Bacterial tracheitis

tracheitis

  • secondary bacterial infectious of trachea, purulent exudates can cause airway obstruction
  • follows viral infection, eg refractory/toxic croup
  • lateral neck Xray shows intraluminal narrowing or irregulaties on trachea
  • broad spectrum antibiotics and admission to pediatrics

Croup

croup

  • laryngotracheitis causes upper airway obstruction after a viral infection
  • presents with barky cough +/- stridor, but should not be toxic or unable to swallow (think bacterial tracheitis or epiglottitis)
  • treatment with oral dexamethasone for barky cough, nebulized epi for stridor
  • AP neck Xray shows “steeple sign”

Diphtheria

diphtheria

  • in un-immunized patients causes barking cough, grey pseudomembranes on the tonsils, and “bull neck” from swollen nodes
  • can cause airway obstruction, myocarditis, thrombocytopenia and renal problems
  • treat with antitoxin, antibiotics and admission

Epiglottis

epiglottitis

  • life threatening inflammation of the epiglottis
  • suspect based on fever, odynophagia, drooling, Xray lateral neck “thumbprint sign”
  • antibiotics and urgent ENT consult

Foreign body

Airway-FB

  • can cause acute airway obstruction, stridor, wheeze, SOB; or recurrent pneumonia
  • complete obstruction –> Heimlich, laryngoscope; partial obstruction –> ENT; suspect occult foreign body –> Xray

Growth

  • if gradual voice changes or difficulties swallowing consider tumour –> refer for scope

Hematoma

hematoma

  • if anticoagulated, trauma or recent procedure, consider hematoma –> urgent scope

Inhalation

burns-sootface

  • if smoke inhalation –> ventolin +/- prepare for difficult intubation

Johnsons (SJS)

SJS

  • immune-complex mediated disease affecting mucous membranes throughout the body, including lips/throat
  • requires airway protection, fluid/electrolyte replacement and ICU admission

Kawasaki

kawasaki-disease

  • muco-cutaneous lymph node syndrome
  • 5 days fever + bilateral conjunctivitis, causes cracked lips, cherry tongue, cervical adenopathy, palmar rash, rash on trunk
  • the swollen nodes and tongue can cause airway obstruction
  • if suspect consult paeds for admission, IVIG and echo r/o coronary artery aneurysm

Laryngitis

  • self-limiting viral infectious causing loss of voice

Mono

  • viral infection causing cervical lymphadenopathy and hepatosplenomegaly
  • complications: upper airway obstruction, splenic rupture, rash after amoxil
  • dexamethasone for airway swelling, avoid sports and r/o splenic rupture if abdo pain/syncope

Node: lymphadenitis, lymphadenopathy

  • lymphadenitis: infected node –> antibiotics +/- I&D
  • lymphadenopathy: consider viral (including HIV), and malignant (eg lymphoma)

O antistreptolysin

  • strep throat
  • Centor score: fever, tender nodes, exudate, no cough, less than 15
  • swab intermediate score, antibiotics for high score (to reduce complications)

Pharyngitis viral

airway

 

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