Epiglottitis rule:

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❑ ❑      What are the 10 D’s of epiglottitis?

Dr Dwight says, “Drooling, Dysphagia, Distress = Dangerous airway!  Don’t touch it!  Dx and Definitive Deed (intubation) in the OR!” 

The Dx is one that require a high degree of clinical acumen!  Exam of the throat with a tongue blade or a flexible laryngoscope is NOT performed in the ED if the Dx is remotely suspected.  The swollen flexible epiglottitis of a child can act like a ball-valve mechanism leading to acute airway obstruction if this toxic child is stressed any further!   
Sample Test item 1/multiple questions.  What is the diagnosis?  What are the radiographic signs you see? what would you expect to find on physical examination? What is contraindicated?  Is anything indicated on an emergency basis?  What is the MC cause?  Is there any ancillary treatment after the emergency has been managed?

Test Item 1 Answers:  No this is not croup, it is epiglottitis. Signs of epiglottitis seen on this upright lateral film:  Child is sitting upright in the sniffing position.  The neck is straight and angled forward at the base of the neck to make the head shift forward.  You see a dilated hypopharynx and can’t visualize the valecula as it is filled with swollen epiglottis.  The epiglottis is oriented horizontally from edema, i.e., you see the thumbprint sign.  This patient needs controlled intubation, ideally performed immediately in the operating room.  On physical exam you may see a febrile, drooling child who is noncommunicative with a muffled voice and only focused on breathing, i.e., he/she is quiet.  The child may be maintaining an upright posture in a tripod position and refuse to lay down while holding both arms extended at the sides.  You may hear gross inspiratory stridor.  Nothing should be done prior to the intubation as it may worsen the child’s condition and cause complete obstruction of the airway.  If loss of the airway occurs most can initially be ventilated with an Ambu bag and mask.  The next choice is needle cricothytomy and/or emergency intubation.  If the child tolerates it, a face mask with oxygen can be held just in front and below the face prior to the intubation in the O.R.  The MCC is S pneumoniae.  Hemophlius type B was the primary cause in children prior to the introduction of the Hemophilus vaccine.  However, there are periodic outbreaks of Hemophilus infections due to failure to vaccinate children. Also the most common age for this condition in children has changed from three years to eight – twelve years. Ancillary treatment:  An IV line is not started until after an ET tube has been secured to avoid complete airway obstruction.  Next a 3rd generation cephalosporin (either cefuroxime, ceftriaxone, or cefotaxime) should be administered and the child admitted to an ICU.  A pneumococcal vaccine and/or Hib vaccine may is indicated. …from Visual Test Items [VSTIs] to be released as a new chapter section in my book The Complete EM Board Prep! © D Collman 2023. I hope to publish this text in 2023-over 600 pages! Look for it in the Fall of 2023.! Reserve your copy now!. This is everything I have ever taught or written about for 40 years to prepare you for the ABEM certifying exam, the ConCertTM exam, and the oral exam in emergency medicine. Completely updated in 2023.!

Published by DrC

Clinical Emergency Physician Prior Faculty for Midwestern University EM Author/Educator/Medical Ilustrator Expertise: EM Pathophysiology and physiology [both pediatric/adult] Designer of a silicone membrane ECMO [extracorporeal membrane oxygenator] By 2005 trained ⅓ of the world’s EPs for EM board certification Trained Oral Examiners for a decade: the Board of Certification in Emergency Medicine [5000 original members...now the second largest EM group in the United States]; he was a compensated consultant for that and numerous other emergency medicine organizations. All of Dr Collman’s presentations have been Co-sponsored AMA/ACEP category 1 CME ACCME accreditation through the AAPS, National and The Fl Chapter of ACEP and The Fl Medical Association since 1989. Publisher of numerous EM manuals, and educational materials [all items were have copyrighted notices and have been sold by the ACEP Bookstore]; all authored by Dr Collman: 2 Vol program syllabus of thousands of Q/As and pathophysiology discussions of all chapters from eds 3-8 of “The Study Guide” [All chapters of the core content knowledge for completion of an emergency medicine residency]; teachs Resususcitation, CV Emergencies, Pulmonary Emergencies, The EKG lab [the 60 most important EKGs/management; Truama Emergencies, Pain Mgmt, Orthopedic Emergencies, Toxicology [Toxins and Antidotes, HEENT Emergies, Environmental Emergencies, Pediatric Emergencies [500 Q/As], HIV/AIDs-Infectious Diseases, Emergencies, Rhematologic Emergencies, Neurologic Emergencies, Acid-Base/ABG Presentation, Dermatological Emergencies, CT/POCUS [point of care ultrasound], Bariatric Emergencies, Endocrine Emergencies. Dr Collman is endorsed by his programs participants [12,000+] Examples: Dr James SULLIVAN MD DABEM; and others program participants described Dr Collman as a “National Treasure” Dr Collman grandfathered into EM after completing a rotating Gen Surg Internship at UCLA School of Medicine [June 1981]. He accepted a directorship position at age 25, the contract to Illustrate “Emergency Management of Pediatric Trauma” [author:Thom Mayor MD FACEP] published by WB Saunders Dr Collman provides strong intellectual support to his program attendees...many chose him to be their permanent career mentor and return annually to his live interactive conferences. Dr Collman has designed computer-based programming to numerous organizations in ACLS algorithms [Univ of Pisstburgh] He provides Interactive grand rounds as Case Simulations by invitation: He designed an 8-h Visual Stimuli Presentation for Johns Hopkins Dept of EM [their board prep program;a second 8 hr presentation “The Genitourinary System-a Comprehensive 8-hour Review”; he teaches each program Johns Hopkins University. He trained Examiners for the BCEM [AAPS] Atlanta GA: presented a combined certification review [both certification part I/orals] numerous time in Atlanta, Hawaii, Lake Tahoe, and Orlando, Fl 1991-1996. He created their entire bard exam [part I and Oral Examination and a computer-operated Visual Examination [2 Versions] in 1996. This included 700 certification test items and 25 Oral Examination Live Test Simulations as well as trained their AAPS [BCEM Examiners twice a year for 10 years [throughout the 1990s] Texts Authored Editor in Chief 4th-7th Ed of: “Pearls of Wisdom in Emergency Medicine [7 eds] and 35 Cds [33 are critical analysis of the 52 OBT Live CD set: audio recording made Live at Conference [cost $1515.00 (Oral Board Case studies)+ ASA/APAP toxicology CDs [each is 1 hour w/manual purchase price $65.00 for each + “CT Video: CT for the Emergency Physician”. Videotaped Live in Boca Raton, FL by Pear Productions Publication Study Quote: “Dwight Collman MD DABEM DABFM Provides the most rigorous CME Education”...documented by EM News and EMRA [in 2002 ranked Dr Collman’s EM 8-Day Interactive Review! with the top 8 University or top ACEP chapter programs [an independent study they published for all of America’s Emergency Medicine Residents preparing for their board certification examinations. 2009 Jan Issue EM News Editor-in-chief ranked Dr Collman as the “premier educator for board preparation in the US” Core Competencies: Bedside Clinical Instructor all EM Medicine Clinical assessment/training EPs in all EM Procedures [over 90 procedures] Core competency: illustrates human Anatomy as it pertains to EM/EM procedures [he does this Live and his clients request to keep his illustrations] Dr Collman edited Emergency Management of Pediatric Trauma [while he illustrated this First-Ever Text devoted to Pediatric Trauma; he spent 2 years creating the illustrations for this text 1983-1985 and they were reproduced and resold by the publisher and appear in the Pediatric Trauma Capter of The Text: The Clinical Practice of Emergency Medicine” Ed 1., author Ann Lattimer-Harwood-Nuss [now Professor Emeritus, retired]. Completed a Fellowship in Gen Anesthesia: University of Utah School of Medicine Awarded 5 specialty rotations [mentorship programs in medical school:ICU President: Collman Institute Inc [a Fl S-Corp] 1994-2007 . Clinical practice x ~40 Yrs ABEM certification Life Fellow Am Board of Forensic Examiners Trains EPs in triage/emergency Pt care/documentation to mitigate litigation risk Has been awarded teaching contracts from over 400 US Hospitals Trains EPs from every branch of the US Military since 1989 -first group included the CO of the Portsmouth, Va Naval residency [Michael Gonzalez MD FACEP who officially made the Oral Board Tutorial! As mandatory education to graduate his residency program in 1989. I am a “trainer-educator, author, medical Illustrator”. I have treated college students at no cost since the 1990s Additional skills/competencies: Documentation [chart review consultatnt], Test item Writer [wrote the entire certification partI/part II examinations in 1996 Teach/train using interactivity/I teach the statistical/mathematical precognitive approach to physicians for pediatric IV fluid protocols for resuscitation, 3 forms of dehydration, burn fluid calculations + formula for airway [pulmonary burns] 52 simulations in 5 days; the role of the CANs/EXRs; I have a program syllabus for both of my CME programs Program author/presenter: “The Clinical Documentation Of the Emergency Medicine Hospital Chart”, a 2-Day program conducted in Park City, Utah [1992] As a Forensic Examiner he has reviewed and consulted emergency Physician defendants [approx 30 cases over 25 years]

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