A 4-year-old boy presents with high fever, anorexia, and drooling. He has mild inspiratory stridor and resists the nurse's efforts to assist him into the supine position. You should next:
Use a tongue blade to visualize the posterior oropharynx and rule out epiglottitis.
Obtain a portable lateral soft tissue x-ray of the neck with the child in his mother's arms, while arranging airway management in the operating room.
Perform immediate tracheostomy.
Begin high-dose steroid therapy and arrange for a croup tent.
Sedate the patient and place him supine, while starting beta-agonist therapy.
Although it remains one of the most feared childhood emergencies, pediatric epiglottitis has markedly declined in incidence in the last several years following the widespread use of the Haemophilus influenzae B (HIB) vaccine. Pediatric epiglottitis typically affects children between 3 and 7 years of age and occurs year round. Typically, there is an acute onset of a severe sore throat and high fever with drooling and dysphagia. The child often sits with the neck slightly extended and chin thrust out to open the airway. Air hunger and retractions are common, while coughing is absent. The child resists efforts to be placed supine, but otherwise sits quietly with all efforts directed toward breathing. The child with suspected epiglottitis should not be left unattended by the physician. A bag-valve mask with oxygen, endotracheal tube, laryngoscope, and a 14-gauge needle-catheter for needle cricothyrotomy should be kept close at hand. Attempts to visualize the epiglottis with a tongue blade should be avoided as they may precipitate airway occlusion and respiratory arrest. A lateral neck film in the ED may help confirm the diagnosis. Optimal treatment includes intubating the patient in the operating room under general anesthesia.