Boring Question: How useful are bowel sounds?

This month we launch the first post in a new series entitled “Boring Questions”.  This column will focus on reviewing key literature around common questions that might be asked during a shift.  – Teresa Chan (Managing Editor)

Clinical Scenario:

A 60-year-old female presented to the emergency department with a 24 hour history of lower abdominal pain. The pain had increased in intensity over the past day and was 7/10 on presentation. She has been nauseated for the past 12 hours with no episodes of emesis. She was not sure when her last bowel movement was and she also described feeling bloated. Her only previous surgery was an appendectomy (1980).  She had no urinary complaints and had not been sexually active in the past year. She denied eating any food out of the ordinary for her.

On physical examination her vitals were:

Temp: 37.5, HR: of 80,  RR: 16,  BP: 132/82, O2: 98% on room air.

She was moving in bed with the seeming discomfort. Her abdomen appeared distended with no surgical scars. She did not have any rebound tenderness or guarding to palpation. She was in mild discomfort with pain to palpation of both the left and right lower quadrant. Her digital rectal examination did not reveal any occult blood per rectum (usefulness of this test to be reviewed at a later date).

The Boring Question:

How useful are bowel sounds for a patient with abdominal pain and potential small bowel obstruction?

Background:

Auscultation of the abdomen  to evaluate motility and mechanical properties of the bowels is a well-established part of the physical examination but its clinical value has been understudied (1). Historically it has been taught that decreased bowel sounds may suggest ileus, mesenteric infarct or narcotic use while hyperactive bowel sounds, might suggest small bowel obstruction (SBO) (2).

Search Strategy:   

Using PubMed, two separate searches were performed. These were:

  1.  ‘Bowel Auscultation’ AND ‘Abdominal Pain’
  2. ‘Bowel Sounds’ AND ‘Abdominal Pain’.

The resulting abstracts were screened with relevant articles reviewed. In addition to the literature, the textbooks ‘Tintinalli’s Emergency Medicine’ and ‘Evidence-Based Physical Diagnosis’ were also reviewed.

The Evidence:

  • Evidence-Based Physical Examination reviews data that suggests that 40% of SBO patients have hyperactive bowel sounds, while 25% have diminished/absent bowel sounds (4). From this, the author surmises that  35% of patients with SBO have normal bowel sounds which gives a -LR of SBO of 0.4.  This is a moderate likelihood ratio that could be helpful as a diagnostic test but the author also admits that determining whether bowel sounds are hyperactive, normal or hypoactive is not objective and there are many associated variables including quadrants, time since last meal, normal bowel function etc.
  • A more recent investigation by Felder et al. in 2014 prospectively recorded bowel sounds from patients with normal gastrointestinal motility and small bowel obstruction, diagnosed by CT scan and confirmed in the operating room (1). The positive predictive value for auscultation in normal versus cases of small bowel obstruction was found to be 23% (CT diagnosed) and 28% (OR diagnosed) (1).
  • Similarly, a study by Bohner et al. in Germany assessed 1254 patients (3). This study found that increased bowel sounds had a  sensitivity of 39.6% and specificity of 88.6% (+LR 3.5) for the detection of bowel obstruction. (3). But the same group of patients, decreased bowel sounds also had a positive predictive value was 11.2% (3). It is important to note issues with this investigation which include a broad age group from 9 to 97 years with no demographic analysis (3).

Bottom Line:

There is little literature on this physical exam technique the available evidence suggests that bowel sounds are not an objective or reliable method to assess patients for small bowel obstruction.

References

1. Felder S, Margel D, Murrell Z, Fleshner P. (2014) Usefulness of Bowel Sound Auscultation: A Prospective Evaluation. Journal of Surgical Education In Press . Link

2. Tintinalli’s Emergency Medicine-A Comprehensive Study Guide (2011). New York. McGraw Hill Companies Inc. Link

3. Lamont C. (2011). Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4. How useful are bowel sounds. Emerg Med J. 28 (4): 336. Link

4. McGee S. (2007). Auscultation of the Abdomen. In Evidence-Based Physical Diagnosis (588-593). Philadelphia: Saunders Elsevier. Link

Reviewed by Eve Purdy (Student Editor), and Teresa Chan MD FRCPC (Managing Editor)

Author information

Jatin Kaicker
Jatin Kaicker
Jatin Kaicker is a Family Medicine resident at McMaster University.

The post Boring Question: How useful are bowel sounds? appeared first on BoringEM and was written by Jatin Kaicker.

ADJUST-PE: Should we adjust the D-Dimer cut-off for age?

Pulmonary embolism is a diagnosis that haunts emergency physicians’ nightmares. Its potential deadliness and the variability of its presentation, combined with the potential harms of CTPA’s and overdiagnosis, make assessing it in the low to moderate risk patient devastatingly frustrating. Decades of research have armed us with the PERC Rule, Wells Criteria, Geneva Score, and D-Dimer, but the war is far from over. Some of the latest progress has focused on modifying our use of the D-dimer to maximize specificity while maintaining sensitivity. There is a particular need for this in the elderly population because D-Dimer levels increase with age (PMID:11020391).

Last year I (@Brent_Thomareviewed a systematic review and meta-analysis that attempted to validate the age-adjusted D-dimer cut-off (age x 10 in patients >50 years old). While this study showed promise, I had several qualms with it including the merging of data from both PE and DVT studies (the authors also published meta-analyses on these diagnoses separately: DVT PMID:22511491 and PE PMID:20354012) as well as the inclusion of the rule’s derivation cohorts in the validation analysis. My bottom line was that we probably need a prospective study on the age-adjusted D-dimer before it can be applied broadly in practice. In March of 2014 we got one: The ADJUST-PE study.

The ADJUST-PE Study

PICO Table

Population 3346 consecutively recruited patients presenting to European ED’s with chest pain or shortness of breath of unknown etiology.
Intervention Age-adjusted D-Dimer cut-off for diagnosis of PE (cut-off = age x 10 if >50 years old OR>500 if < 50 years old)
Control None
Outcome Safe discharge (no DVT or PE) during a 3 month follow-up period as assessed by both documented interactions with the medical system and a phone interview.

Outcome

52761844The study was designed to assess the safety of using an age-adjusted D-Dimer, however, the abstract and results focused on the entire population of adult patients. Of the 3346 patients included in the study, only 337 (11.6%) were in the population of interest: those treated based on an age-adjusted D-Dimer (the rest were <50 years old, had a D-Dimer <500mcg/L, had a D-Dimer > the age adjusted cut-off, or were deemed high-risk and evaluated with a CTPA). This represents a 16.9% (6.4% to 23.3%) absolute increase in the number of patients >75 years old that were below the D-Dimer cut-off (this data was not reported for 50-75 year old patients).

Of the 337 relevant patients 6 were excluded because they were started on anticoagulation for another reason, leaving 331 patients. None were lost to follow-up and only 1/331 (0.3%, 95% CI 0.1-0.7%) had a thromboembolic event in the next 3 months while 6/331 died due to other causes (as determined by adjudication). Notably, 3/6 of those patients died from “end-stage COPD.”

Discussion

The ADJUST-PE study assessed whether or not a negative diagnostic strategy that included an age-adjusted D-Dimer cut-off was able to identify a population at low risk of thromboembolic disease in the next three months.

The major criticism I have of this study is that they did not use the gold-standard test (CTPA) for PE in the population of interest (the 331 patients with a D-Dimer that was >500mcg/L but below the age-adjusted cut-off). Effectively, this study tested the D-Dimer as a prognostic (rather than diagnostic) test because they did not confirm that a negative D-Dimer meant that their patients did not have a PE at presentation – they confirmed that they wouldn’t be diagnosed with a new PE or DVT in the next 3 months. While there is some merit to using 3-month follow-up because it answers an important, patient-centered prognostic question (Is this patient going to have a PE if they are not anticoagulated?), it bugs me because in practice we use the D-Dimer diagnostically (we want to know that the patient doesn’t have a PE! Not that they won’t have a DVT/PE in the future). Further, the prevalence of PE, while high in the entire study population, was not stated in the relevant subgroup (if it was lower, the test would perform better).

52762021The response to this criticism is that assessing who will have thromboembolic disease of consequence is more important than determining if they have a PE and that any PE’s that were missed were likely small. That is true. However, because they did not perform the gold-standard test we can not say with any certainty that this is the case. Further, we are not able to assess the operating statistics (sensitivity, specificity, +LR, -LR) of the age-adjusted D-Dimer cut-off in comparison to the traditional D-Dimer cut-off because we do not know who has the disease.

Based on above, some potential sources of bias within the study are “double gold standard bias” (the group that tested positive got the gold standard CTPA while those that tested negative got 3 month follow-up), “imperfect gold standard bias” (3 month follow-up is an imperfect gold standard), and verification bias (only those that had a positive D-Dimer got the true gold standard test making it more likely for them to be diagnosed with PE and less likely for the group with a negative D-Dimer). Additionally, the adjudicated declaration that the 6 deaths in the population of interest were not due to PE is suspect because three of them died of “end-stage COPD,” a diagnosis that is likely to be clinically indistinguishable to PE in the charts following the event.

A couple other limitations include the use of two clinical decision tools (Geneva and Wells) and six D-Dimer assays in the study. Although there is data on the clinical decision tools elsewhere and the D-Dimers seemed to have fairly consistent performance, it is difficult to know if the described diagnostic strategy will perform as well as it did in this study in specific scenarios.

Conclusion

This observational study found that an age-adjusted D-Dimer can be used safely as part of a diagnostic strategy in adult patients presenting with suspected PE while increasing the number of patients >50 years of age with negative tests. There is a need for additional prospective studies on this question as this one contained only a small number (331) of patients that were relevant to the study question. While it is not enough to change guidelines, I think it is reasonable to use the data from this study to discuss the risks and benefits of CTPA in patients with a D-Dimer levels below the age-adjusted cut-off and come to a shared decision in some situations.

Alternative Perspectives

Salim Rezaie (@srrezaie) of REBEL:EM, Rory Spiegel (@EMNerd_) of EMNerd, Ryan Radecki (@emlitofnote) of EMLitofNote, and Andy Neill (@AndyNeill) of Emergency Medicine Ireland have also discussed this study. In particular, Rory Spiegel’s post is pure gold that is worthy of a read. He digs much deeper into the literature surrounding both the CTPA and DDimer and comes to a much more nihilistic conclusion.

Thanks to Teresa Chan (@TChanMD) and Salim Rezaie (@srrezaie) for reviewing this post.

Author information

Brent Thoma
Editor in Chief at BoringEM
Emergency Medicine Resident at the University of Saskatchewan, wannabe Medical Educator, Blogging Geek. + Brent Thoma

The post ADJUST-PE: Should we adjust the D-Dimer cut-off for age? appeared first on BoringEM and was written by Brent Thoma.

Tiny Tips: Non-Cardiogenic Pulmonary Edema / ARDS

When you see a pulmonary edema on chest x-ray (CXR), the knee jerk reaction is to attribute it to heart failure.  But what might you be missing?

Not all the glitters is gold. And not all that is wet on CXR is just plain ol’ CHF.

Non-Cardiogenic Pulmonary Edema (NCPE) is better known to the world when it it is at its most severe form – i.e. ARDS (Acute Respiratory Distress Syndrome) or ALI (Acute Lung Injury).[1] However, for the purposes of linking the concept to the mnemonic (and the CXR findings), I have chosen to file it as a Tiny Tip under NCPE.

First recognized in military casualties in the first and second World Wars, NCPE is a commonly discussed entity in critical care.  In fact, an international group of experts has met in Berlin recently to redefine the definition of ARDS/ALI (see the post by the LIFTL guys on this topic for a great primer). [2,3] NCPE can be caused by direct insults to the lung tissue or indirect mechanisms such as systemic inflammation.

Mnemonic  for Causes for Non-Cardiogenic Pulmonary Edema

IS NOT THE HEART

I nhaled Toxins (Ammonia, Chlorine, Phosgene, Nitrous oxide)
S IRS / Sepsis / Septic Shock

N eurogenic (seizure, strangulation, trauma)
O verdose (Heroin, methadone, cocaine)
T hyrotoxicosis

T rauma
H eat (Smoke! Remember to also consider carbon monoxide!)
E lectrocution

H igh altitude pulmonary edema
E mbolism (Pulmonary Embolism, Acute Gas Embolism, Amniotic Fluid Embolism)
A SA toxicity
R eperfusion or Re-expansion pulmonary edema (or Rocky Mountain Spotted Fever – This one is in here for the PGY5s: May the Force be with you until your quiz next year)
T ransfusion

Remember, this is NOT a comprehensive list, but it is a list that can help you think through alternative causes of a “wet” CXR.  Causes that it does not contain include Uremia, Cardiopulmonary bypass, DIC (RMSF is in the above list mostly due to this), other coagulopathies, pancreatitis… and more.

The mnemonic for this Tiny Tip, as well as a bunch of others, can be accessed and memorized using spaced repetition through Boring Cards as outlined here.

References

1.  Perina DG.  Noncardiogenic pulmonary edema.  Emerg Med Clin N Am ;21 (2003) 385–393. PMID: 12793620.

2. Nickson C.  Acute Respiratory Distress Syndrome (ARDS) Definitions. Life in the Fast Lane. Revised April 16, 2014.  Accessed July 13, 2014.  Available at: http://lifeinthefastlane.com/education/ccc/acute-respiratory-distress-syndrome-ards-definitions/.

3. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33. doi: 10.1001/jama.2012.5669. PubMed PMID: 22797452.

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Tiny Tips: Non-Cardiogenic Pulmonary Edema / ARDS appeared first on BoringEM and was written by Teresa Chan.

Counterpoint: Think Medical School is for you? Be brave.

This Counterpoint is an open letter that was written in response to a recent Globe & Mail commentary (Think medical school is for you? You’re probably wrong) which took a pessimistic perspective on the pursuit of medicine as a career. This is the fifth in a series of replies written by the BoringEM team that will feature the perspective of a physician at a different stage of their medical career.

This piece contains the reflections of a resident physician, Sarah Luckett-Gatopoulos (BoringEM Resident Editor), who has just newly graduated from medical school.

Please join in this conversation by tweeting with us using the hashtag #DearPreMed.  

Dear Aspiring Medical Student,

I graduated medical school in May, began my post-graduate training in July, and am now a first year emergency medicine resident. You received some pretty terrible advice recently in the form of an article that implied that medicine is a lazy choice, fueled by either naïve idealism or disingenuous claims that belie a desire for money, prestige, and power. You were advised to re-think your desire to pursue medicine, which would inevitably end in burnout and dissatisfaction.

I have some advice for you, too: Be brave.

Be brave, because nothing will be required of you as much as courage will be in the coming years.

Medicine is an exciting but harrowing journey, and it starts with the tedium of MCAT review books, the excruciating vulnerability of personal statements, and the heart-pounding anxiety of hitting ‘submit’.

I struggled with the MCAT, spending long evening hours poring over molecular models, etching pages of physics equations into my exhausted brain, and reviewing redox reactions before I fell asleep each night. The hardest parts of the application, though, were writing personal statements. It was difficult to articulate my goals for my medical career, to write down what I thought I could bring to the field of medicine, and to argue I was as worthy as any other applicant of a coveted spot in one of our country’s medical schools. I was an outsider to medicine, but no one – not even those born into the cult of Aesculapius – can understand what medical education feels like before she is there. Before you crack the first textbook or meet your first patient, you do not know what your personal journey will be like. You may interrogate your mentors hoping to gain insight, but you are unique, and your experiences will be different. Ultimately, courageous self-examination is your surest route to understanding your suitability for medicine at this early juncture.

 

Be brave, because you will learn very soon that neither naïve idealism nor the love of money, prestige, and power can carry you through the difficult early years of your training.

In my first year, I battled heart-rending homesickness. My undergraduate education in psychology and music studies had furnished me with almost no knowledge of anatomy and physiology, and I grappled with ‘basic’ course work. I wallowed in feelings of inadequacy and disconnectedness. I considered dropping out.

It was in those moments of serious contemplation that I searched myself and those around me for reasons to stay. None of my reasons was a hope for a big paycheque. As I had my first patient contacts, I found that my desire to help was genuine and heartfelt. This desire was stronger and more satisfying than any other reason listed by Ms. Sinclair. You will feel inadequate and uncertain, too, and if you are brave enough to examine those feelings, you (and your patients and colleagues) will be richer for it.

 

Be brave, because you will confront things about yourself you wish you didn’t know.

I was horrified to find myself resenting a patient who had returned to the emergency department under life-threatening circumstances because she didn’t heed my advice the first time I saw her. I was appalled on the day that I found myself judging a patient for smoking when I saw him in clinic with lung cancer. I was saddened on the day I realized that I was not motivated to help an obese patient with knee pain who would not lose weight. I was challenged to become more reflective, to understand my reactions to these patients, and to learn to approach them with compassion. Medical training is a journey of self-discovery, and not everything you will learn about yourself will be pretty. If you are honest and courageous in facing your shortcomings, you will become a trustworthy clinician.

 

Be brave, because you may, at some point, be drenched in the heat of someone’s blood, urine, and vomit, but you will feel the burn of their disdain more acutely than any physical discomfort.

In search of diagnosis or therapy, you will hurt patients and be unable to explain to them how you are helping. You will be yelled at, at least once during clerkship, by a patient. You will be faced with an attending who is condescending. You will deal with a resident who treats you as a personal assistant.

In my final year of medical school, I was yelled at by a patient whom I had cared for over the previous week. He called me names that I had never been called before. If you are brave, you will learn that you need not be a lightning rod for someone else’s abuse. If you are courageous, you will learn to stand and speak calmly when those around you are shouting. And you will learn to advocate assertively for your patients, even when they do not thank you. As you learn to speak about the times when you feel used, abused, or ignored, you will find comfort in your peers and you will become a resource to them when they are similarly challenged.

 

Be brave, because you will watch someone die, and you will feel helpless.

In my third year of medical school, I watched a patient die in the emergency department. The patient could not be saved, but we were not useless. The ED team brought her family in to hold her hand as she went. If you are brave, you will learn that you can care even when you can’t cure.

Be brave because July 1st of your inaugural year as a doctor creeps up on you in the same way your application due date is creeping up on you now – slowly first, then all at once – and you may find yourself in an unfamiliar hospital in an unfamiliar city, pens and ACLS cards stuffed into a pocket of your greens, while you supervise a case with a medical student. You will co-sign his note, taking responsibility for whatever happens to the patient under his care, you will help him write an order, and then you will be paged back to the ward with a screech and a buzz because someone is bleeding, vomiting, or in pain. Your heart will pound like you’ve run a marathon, but if you are brave, this is when you will learn.

Think medical school is for you?

Be honest with yourself.  You won’t know, but this will help you decide when the time comes.

Be vulnerable with your friends and colleagues.  They will help you throughout your journey.

Be careful with your time and self-care. In the wise words of your flight attendant, you must help yourself before you can help the passenger next to you.

Medicine is neither a lazy choice nor an easy path.

 

Be brave, because the journey will demand it.

 

With much love, your future colleague,

S “Luckett” LG
Resident Physician

This part 5 of the #DearPreMed Series in the Life in Medicine section of BoringEM.

Edited by Teresa Chan (@TChanMD), Brent Thoma (@Brent_Thoma), and Eve Purdy (@purdy_eve)

Author information

Sarah Luckett-Gatopoulos
Sarah Luckett-Gatopoulos
Junior Resident Editor at BoringEM
Sarah is a resident at McMaster University. She has an interest in creative writing and health literacy.

The post Counterpoint: Think Medical School is for you? Be brave. appeared first on BoringEM and was written by Sarah Luckett-Gatopoulos.

Introducing our Newest Teammate: Sarah Luckett-Gatopoulos, BoringEM Junior Resident Editor

Dear BoringEM readers,

We’re proud to announce more changes for BoringEM. (I know, such exciting moves for our “boring” little site!)  We’ve been actively reinvigorating our site’s organizational structure to become a multi-author, academic, #FOAMed blog.  We hope by having a larger team it will increase our sustainability and bring more frequent high-quality content to you, our reader.  As such, we have been recruiting new team members.  It is my pleasure to announce now that we are expanding our editorial team once again: Dr. Sarah Luckett-Gatopoulos will be joining us (@SLuckettG) as our new Junior Resident Editor.

“Luckett” (@SLuckettG) has just graduated from Queen’s University where she has served as an editor for their local medical student journal.  She is now a freshly minted Emergency Medicine resident at McMaster University’s Royal College program.

Her interests are in literacy, health advocacy, and near-peer mentorship.  She has previous editorial and writing experience, as she has previously been part of the editorial team for various publications at her medical school (Queen’s university).  As a junior resident, she brings the unique perspective of a doctor in that liminal space between student and doctor. Sarah will be participating in the pre-publication editorial review process and also writing her own material, mainly within the mentorship section.

Please join us in welcoming Luckett to the BoringEM team.

Teresa Chan   MD  FRCPC
Managing Editor, BoringEM

P.S. Stay tuned for Luckett’s first Counterpoint editorial that will debut later today!  Her’s will be one of the many essays in our #DearPreMed featured series.

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Introducing our Newest Teammate: Sarah Luckett-Gatopoulos, BoringEM Junior Resident Editor appeared first on BoringEM and was written by Teresa Chan.

Adult Epiglottitis: Not just a hot potato

It was an early morning shift at Janus General when I picked up the chart of a 36-year-old female with a two-week history of sore throat.

I walked into the room and see a healthy looking 36 year old woman. Her vitals were stable, but she was febrile. She was reclining on a stretcher, breathing normally and did not appear to be in respiratory distress. She presented with a two-week history of sore throat with intermittent fever, no cough, no dyspnea, and her voice sounds were a bit high pitched but not exactly muffled.

Looking at her, sitting on the bed, I was thinking viral URI or perhaps strep throat. I certainly was NOT thinking “epiglottitis,” a diagnosis I associate with stuff like this:

Epiglottitis Scheme

As I considered her differential she told me that she came into ED because she has been feeling increasingly uncomfortable for the past 2 days. She was taking naproxen for pain but has found that her “throat spasms” when she drinks water which has made swallowing pills hard. That gave me pause as I started my exam.

The left side of her neck was very tender and mildly edematous. She could only open her mouth a bit because her “throat spasms” every time she tries. I grabbed for a tongue depressor to get a better look and almost sent her into a chocking fit! That left me with no better of a look and an even more distressed patient.

The super-star staff physician working the ED that day noted that the presentation was not typical but that “We should scope to make sure he does not have epiglottitis.” ENT was consulted and she was quickly whisked away for flexible laryngoscopy. Twenty minutes later, I got a page from a very excited ENT physician, “You were so right! It’s epiglottitis!”

The lesson I took from this is that while children are not little adults, adults are not big children either. The presentations of “pediatric” diseases can be subtler and less typical the rare times they present in adults.

Quick and Dirty Facts About Adult Epiglottitis

The incidence of epiglottitis is 1-4 per 100 000 (Solomon 1998) with a mortality of 7-20% (Carey 1996). Common causes can include bacteria (H. Flu type B), viruses (herpes simplex), fungi (candida albicans), and non-infectious irritation (trauma, chemicals, heat, inhalation of heated objects (smoking illicit drugs). Common clinical features include sore throat and painful dysphagia. Less frequent causes that may be predictrors of airway loss (this is controversial) include drooling and stridor.

Differential Diagnosis

  • Deep space abscesses
  • Lingual tonsillitis
  • Laryngeal tumors
  • Toxic/caustic inhalation, aspiration, or ingestion
  • Acute angiodema
  • Aortic dissection

Radiographic evidence

The thumb-print sign is the classical radiographic finding in epiglottitis and is named because the epiglottis seems to swell to the size/shape of a thumb print!

Thumb Print Sign 2

Stanford University Medical Center and Kaiser Permanente, Stanford, CA

fig temp 5col 2 across [Converted]

Pediaatricimaging.wikispaces.com

 Laryngoscopy evidence 

This picture shows an incredibly swollen epiglottis. Note that direct laryngoscopy is not advised because it may provoke airway spasm. This photo was taken with a fiberoptic laryngoscope.

Epiglottitis - Laryngoscopy

Department of Anesthesia and Intensive Care, Chinese University of Hong Kong

Treatment

Patients are typically admitted to a monitored bed for close airway monitoring and intravenous antibioitics. Antibiotics should be started immediately and cover haemophilus influenza, staph aureus, streptococcus, and pneumococus. The drugs of choice are generally amoxicillin/clavulanic acid or a third generation cephalosporin (Ward 2002). NSAIDS can be used for symptomatic relief and corticosteroids are often recommended although the evidence is controversial. Two separate studies, Dort (1994) and Mayo-Smith (1995), have shown that their use does not reduce the need for and the duration of intubation, or the duration of ICU stay.

The role of airway intervention in adults is controversial and a more conservative approach is recommended (antibiotics, corticosteroids, and humidified oxygen). Some studies suggest basing the decision on patient’s clinical signs and symptom. Factors to consider include respiratory distress, stridor, sitting erect, inability to swallow secretions, and deterioration within 8-12 hours. Other studies propose management based on laryngoscopy findings. Intubate if signs of severe constriction of the supraglottic space and/or vocal cords not visible and/or endotracheal intubation not possible (Wick 2002).

For intubating a patient with epiglottitis, check out Dr. Rich Levitan’s great article from 2011 which offers the following tips:

  • Rescue ventilation (LMA, King LT, mask ventilation) may not work in a patient with laryngeal pathology
  • Supraglottic airways (LMA, King LT) may obstruct the airway further by pushing the swollen epiglottis over the laryngeal inlet
  • If orotracheal or nasotracheal intubation fails, a rapid surgical airway might be required
  • Mark the neck in an event that surgical airway becomes necessary
  • Flexible fiberoptics are ideal for intubating a patient with laryngeal pathology
  • Pharmacological adjuncts (small doses of benzodiazepines and ketamine) should be used to aid in intubation
  • Topical medication can be used to help relax the surrounding structures (lidocaine 20cc of 2% can be nebulized)
  • Maximize oxygenation efforts throughout the intubation by applying nasal oxygen
  • After intubation, take care in preventing unintended extubation through the use of sedatives and muscle relaxants
  • Equipment for a surgical airway should be kept at bedside, even after intubation, in case of unexpected extubation

Conclusion

Childhood incidence of epiglottitis has decreased significantly since the routine use of HiB vaccine.  Despite an increase in adult cases, it still remains a rare presentation seen in the ED.Adult presentations tend to be subtler than that of children with sore throat, dysphagia, and odynophagia being the more common symptoms (Durell 2011). Often, adult patients not present with signs of airway obstruction, leading to an overall delay in diagnosis (Ng 2008). Prognosis is good, but it’s important to keep it on your differential diagnosis for an adult with a history of sore throat.

 

This post was edited and peer-reviewed by Teresa Chan (@TChanMD) and Brent Thoma (@Brent_Thoma).

Author information

Tanya Viaznikova
Tanya Viaznikova
PGY2 at The Department of Family Medicine, Queen's University

The post Adult Epiglottitis: Not just a hot potato appeared first on BoringEM and was written by Tanya Viaznikova.