Rosen & Barkin's 5-Minute Emergency Medicine Consult (425 page)

BASICS

• In a couple of places (concerning airway and oxygenation) I put one of the references in parentheses to direct the inquisitive to an article in Annals of Emergency Medicine that many will not have heard about. This is different than what the format usually directs, and these can very easily be cut.
  
• Also, following GlideScope and EZ-IO being mentioned, I followed the format seen in other publications of putting the company name and address in parentheses following first mention of the devices in the text. These can obviously be omitted
  
• Named for German physician Wilhelm Friedrich von Ludwig, who 1st described this in 1836 as a rapidly progressive, gangrenous cellulitis and edema of soft tissues of the neck, floor of the mouth
  
• Gangrene is serosanguineous infiltration with little or no frank pus or primary abscesses
  
  • Contiguous spread may encircle the airway or involve the mediastinum
    
  • Emergent interventions rarely include surgical or aspiration techniques
    
• Most deaths are due to airway compromise, occlusion, and resultant asphyxia
  
  • Mortality exceeded 50% in preantibiotic era, currently <8%
    

• Odontogenic in 90% of adult cases, usually from 2nd, 3rd mandibular molars
  
• Less commonly: Mandibular fractures, oral lacerations, contiguous infections, errant drug injections, tongue piercings
  
• Polymicrobial:
  β-hemolytic strep
  commonly associated with anaerobes such as peptostreptococcus, pigmented bacteroides
  
  • Microbiologic analyses may guide therapy
    

• Frequently no clear etiology or site of origin
  
• Ideally, a destination facility will have specialty expertise available (surgery and subspecialties, anesthesia) and be properly equipped to provide emergent intervention
  

DIAGNOSIS

• Nonspecific constitutional symptoms: Fever, malaise, anxiety
  
• Pain: Tongue, throat, jaw, chest, neck stiffness
  
• Dysphagia, dysphonia
  
• Dentition, dental care suboptimal
  

• Febrile, toxic, tripod “sniffing” posture
  
• Stridor, “hot potato” voice
  
• HEENT:
  
  • Tongue progressively displaced upward in both posterior, anterior directions at unpredictable rate
    
  • Airway increasingly compromised
    
  • Drooling, salivary incontinence
    
  • Trismus impedes diagnosis and complicates treatment measures
    
• Physical exam findings beyond those of the head and neck area are often noncontributory or unrelated
  

• The diagnosis is usually clinically evident
  
  • No study or procedure needed to confirm the diagnosis
    
• Loss of airway patency can be unexpected, precipitous, and calamitous
  
• Securing airway patency and initiating treatment take precedent over workup considerations
  

No test will establish the diagnosis; assess severity or direct therapy

Contrast-enhanced CT:

• CT of the neck with IV contrast enhancement is the study of choice:
  
  • Standard cross-sectional imaging extends from skull base to aortic arch
    
  • Best for evaluating the mediastinum, deep space infection location and extent, degree of airway involvement.
    
  • Findings include streaky or “dirty” fat in areas of inflammation; adenopathy (submandibular, submental, anterior and posterior cervical chains); perhaps pus or gas formation
    
  • Potential limitations: Patient must remain supine for the study duration. Scanning location often away from optimal resuscitation, intervention capability.
    

Plain Radiographs:

• Soft tissue lateral neck x-ray
  may demonstrate altered anatomy, especially in the upper airway
  
• Chest x-ray
  of little utility, including detecting presence and extent of mediastinal involvement
  
• Panorex
  may detect odontogenic or mandibular pathology, but of no use imaging soft tissue
  

Contrast-enhanced MRI:

• Information obtained is the same, of no greater value than contrast-enhanced CT:
  
  • Potential limitations: patient must remain supine, motionless for the study duration. Scanning location often away from optimal resuscitation, intervention capability.
    

Ultrasound:

• Detects gas in tissues, abscesses, reactive lymphadenopathy
  
• May locate, outline the airway amongst edematous, distorted tissues of the anterior neck
  
• A guide for abscess or fluid aspiration
  

No surgery or invasive procedure will establish the diagnosis, assess severity, or direct therapy

• Infectious: Cellulitis, epiglottitis, tracheitis, peritonsillar abscess
  
• Traumatic: Penetrating injury, sublingual hematoma from fracture, soft tissue injury
  
• Angioneurotic edema
  
• Neoplasia
  

TREATMENT

• Transport in position of comfort
  
  • Allow adult tripod “sniffing” position, to suction themselves
    
  • Allow pediatric transport, simple interventions (blow-by O
    ₂
    , nebulizer treatments) on mother’s lap
    
• Maximize oxygenation:
  
  • FIO
    ₂
    of 100%
    
  • Consider concurrent O
    ₂
    delivery systems, such as facemask and nasal cannula
    
• Jet insufflation: An infrequently used temporizing rescue device for oxygenation
  
  • Potential limitations: Few experienced with device assembly or use.
    
  • Newer rescue devices easier to place and use.
    

• Minimize patient upset, agitation
  
  • Allow transport, simple interventions (blow-by O
    ₂
    , nebulizer treatments) in parent’s embrace.
    
  • Question the necessity for any interventions: IV access, blood draws, O
    ₂
    mask, monitor leads.
    
  • Transport to facility best able to care for this complex patient if possible.
    

Airway Measures

• Maximize oxygenation
  
• Maintain in position of comfort
  
• Gather supplies/personnel for back-up airway techniques
  
• See “Airway Management” below.
  

• Vascular access: Provides rapid, titratable, predictable medication delivery
  
  • Intraosseus (IO) access useful with poor peripheral access, resuscitations, pediatric access, adverse prehospital conditions
    
  • Commercially available device provides IO access rapidly, effectively
    
• 2nd access recommended: Rescue backup, concurrent polypharmacy.
  

• Immediate priorities are to secure the airway and to institute medical treatment. Diminishing consensus on need for acute surgical intervention other than airway related.
  
• Infrequently see treatable abscess formation, fluid collections on initial presentation.
  

Airway management:

• Rescue airway devices may be difficult to place, altered effectiveness due to anatomy distortion, trismus, excessive secretions
  
• Avoid blind intubation techniques to reduce laryngospasm, iatrogenic injury, bleeding, further tissue distortion
  
• Equipment considerations:
  
  • Smaller ET tubes
    
  • Prelubricate with gel or viscous lidocaine
    
  • Use stylet or bougie for tube support
    
  • Bend distal tube into “hockey stick” shape
    
• Rapid-sequence intubation (RSI) agents may cause abrupt loss of muscle tone, airway architecture, or precipitate airway compromise
  
• Concern for impending respiratory failure increases with stridor, voice change, trismus, tripod posture, sialorrhea
  

Definitive management:

• Traditional surgical gold standard: Tracheostomy using local anesthesia:
  
  • Potential difficulties: Surgeon, specialist availability, facility capabilities not uniform
    
• Traditional nonsurgical gold standard intubation using fiberoptic guidance:
  
  • Potential difficulties: Fiberoptic scopes expensive, fragile, require specific cleaning regimens. Short scopes often lack suction or irrigation ports, visualization easily impaired. Their use is not intuitive to the infrequent operator
    
• Best management option “double setup”
  
  • Patient in an operating theater equipped, prepared to establish surgical airway
    
  • Nonsurgical intervention attempted
    
  • Immediate surgical intervention if unsuccessful or clinical deterioration
    
• Intubation:
  Anticipate distorted anatomy:
  
  • Sitting, awake a preferred option
    
  • Sequential topical applications
    

• IV administration:
  Preferred route of administration as previously outlined
  
• IO considerations:
  
  • Lidocaine flush reduces infusion pain
    
  • Flow rates same as IV for routine fluids, medication administration
    
  • Avoid hyperosmolar agents, potential marrow injury
    
• Antibiotics:
  Empiric use of broad-spectrum antibiotics justifiable, for use until return of culture and antibiogram results, which should direct further therapy:
  
  • Ampicillin/sulbactam: 1.5–3 g IM/IV q6h (peds: 300 mg/kg/d div. q6 if <1yr, <40 kg; 1.5–3 g IV q6h if >1 yr, >40 kg); max. 12 g/d
    
  • Cefoxitin: 1–2 g IV q6–8h (peds: 80–160 mg/kg/d div. q4–6h); max. 12g/d
    
  • Clindamycin: 600–900 mg IM/IV q8h (peds: 15–25 mg/kg/d div. q6–8h)
    
  • Piperacillin/tazobactam: 3.375 g IV q6h (peds: If >9 mo, <40 kg; 300 mg/kg/d IV div. q8h)
    
  • Ticarcillin/clavulanate: 3.1 g IV q4–6h (peds: If >3 mo, <60 kg; 200–300 mg/kg/d div. q4–6h)
    
• Analgesia:
  Pain control should be a primary concern
  
• Antiemetics:
  Proactive, prophylactic use for medication-related or condition-induced symptoms
  
• Steroids:
  Recommend empiric use of longer acting steroids to reduce:
  
  • swelling
    
  • inflammation
    
  • systemic stress dose replenishment
    
• Hyperbaric oxygen:
  Consider if mediastinitis or necrotizing fasciitis