Complications and Pre-Hospital Management of Epiglottitis - Essay Example

Paramedic assessment of a case study Table of Contents Introduction 3 2.Case study 3 3.Diagnosis 4 4.Differential diagnosis of epiglottitis 5 5.Epidemiology of epiglottitis 7 6.Pathophysiology of epiglottitis 8 7.Complications of epiglottitis 9 8.Pre-hospital management of epiglottitis 11 9.Conclusion 13 10.Bibliography 14 1. Introduction The nature of paramedic training program impact the trainees with adequate knowledge to be critical and creative thinkers in the assessment of emergency situations (O’Meara et al. 2012, pp. 63 -78). Efficiency is the hallmark of the achievement of the desired outcome from the treatment offered by paramedics at the first time a patient is met in an emergency situation. It is therefore crucial for a paramedic to perform an own assessment of the condition of the patient to determine the diagnosis of the patient that will help in designing the most probable cause of intervention in an emergency situation. A paramedic must have an effective assessment, diagnostic and implementation skills to be able to help patients in an emergency (Williams et al. 2009, pp.580–582). To demonstrate the significance of assessment, diagnostic and implementation skills necessary for a paramedic, this paper will focus on a case of a patient (Ryan) who is a three-year-old baby who is experiencing respiratory problems. Analysis of the case study would narrow down to the determination of the diagnosis of the condition, with the inclusion of the possible differential diagnosis of the condition. Based on the selected diagnosis, the paper will then analyze the epidemiology of the condition, as well as the possible contributing factors to the incidence of the condition. Additionally, the paper will discuss on the pathophysiology of the condition, the complications, as well as the management of the condition including the pre-hospital management, which is predominantly under the scope of paramedic personnel. 2. Case study According to the case study, a paramedic responds to an emergency call to the house of a three-year-old patient, Ryan, who is experiencing shortness of breath, a fact that is making the parents of the patient very anxious. According to the parents, the child is experiencing asthmatic attack, however, according to assessment and physical examination, the past medical history reveal that the patient was a preterm birth at 29 weeks and had spent 5 weeks in the neonatal intensive care unit. Additionally, the patient had experienced past several episodes of dyspnea. Based on the history of the current illness, Ryan had been unwell for the past two days, experiencing symptoms like running nose, earache, and general irritability. The patient has equally been experiencing difficulty in eating and drinking with an episode of vomiting reported. The patient has been on analgesics (paracetamol) and Demazin Cold Relief Infant Drops 50ml for one day with no improvement noted. On physical examination, the patient presents with slight cyanosis of the lips, appear lethargic, sits upright, stridor and intercostal retraction, weak cough, and drooling. On observation, the patient scores 14 on a Glasgow coma scale, has a heart rate of 120 b/m, blood pressure of 90/45, skin being hot, sweaty and pale while the capillary refill is excess of 2 seconds. The electrocardiogram reveals a sinus tachycardia with the respiratory rate being 36b/m and SpO2 96%. The chest sound reveals inspiratory stridor and expiratory crackles accompanied by poor breathing and poor entry of air to the base of the lungs. 3. Diagnosis Based on the analysis of the case study as presented above, the diagnosis of Ryan’s condition is epiglottitis. Among the children, epiglottitis presents with upper respiratory infections, fever with chills, drooling and irritability of the throat. Additionally, the condition presents with restlessness, hoarse voice and breathing through the mouth. However, the symptoms of the condition become lesser when the child is sitting upright or leaning forward. All the classical signs of epiglottitis point to the fact that the case of Ryne is a manifestation of epiglottitis. Inferring to the case study, epiglottitis is a bacterial infection that is nosocomial acquired, and being that the patient was a preterm birth and having stayed under intensive care unit, the ventilator support in the neonatal unit is the most probable cause of the infection (Inweregbu 2005, pp.14–17). Owing to the proximity of the epiglottis to the nose and the ears, the signs experienced by Ryan like earache and the running nose are the referred symptoms and pain that are equally indicators of an infection with epiglottitis (Inweregbu 2005, pp.14–17). The patient experiences tachycardia as a result of limited air entry to the lungs for circulation, which is equally responsible for the delayed capillary refill. Fever, as experienced by the patient, is an indication of an infection while the abnormal chest sounds are a classical indication of an infection in the respiratory tract (Tibballs & Watson 2011, pp.77–82). 4. Differential diagnosis of epiglottitis According to (Sobol & Zapata 2008, pp.551–566) Epiglottitis is an inflammation of the epiglottis, which is a flap at the base of the tongue and responsible for preventing the entry of food into the windpipe. Owing to the location of the structure, epiglottitis can interfere with the breathing especially of the children due to their narrow airway resulting in a medical emergency. Due to the severity of the condition, diagnosis of epiglottitis in an emergency setting is by physical examination and history taking, however, in a medical facility, the condition can be diagnosed by a throat examination using a fiber tube (Glynn & Fenton 2008, pp.200–204). The tube is thus used in the assessment of the nature of the swelling of the throat and the intensity of the condition. X-ray of the throat and the chest is equally a mechanism that can be employed in the diagnosis of epiglottitis. An x-ray can thus be used in the assessment of the severity of the inflammation and infection. Additionally, blood culture of the throat can be sampled and tested in the laboratory to determine the cause of the infection (Sakdinawat & Attwood 2010, pp.840–848). Epiglottitis can be confused with other conditions such as tonsillitis, foreign body aspiration, diphtheria, asthma, and croup (Roy & Lavoie 2003, pp.1–17). However, it is important to conduct a differential diagnosis to ascertain the exact condition as a basis for the provision of effective medical assistant to the patient. To differentiate epiglottitis with tonsillitis, the later presents with erythema of the tonsils, which lack in epiglottitis while in tonsillitis, a lateral neck radiograph would be normal (Georgalas et al. 2009 pp. 16-25). Foreign body aspiration in children equally present with some signs as epiglottitis. However, in foreign body aspiration, there may be a history of a potential foreign body aspiration. Nevertheless, through imaging, foreign body aspiration is differentiated from epiglottitis due to the visualization of the foreign body in an X-ray. Additionally, direct laryngoscopy and bronchoscopy are useful in differentiating the diagnosis of foreign body and epiglottitis. In diphtheria, there is a presence of pharyngeal membrane which is absent in epiglottitis, making differential diagnosis possible, direct visualization examination is useful for differential diagnosis of diphtheria and a microbiology assay is positive for Corynebacterium diphtheriae in diphtheria. Croup occurs in small children and the symptoms become less severe as the child grows due to enlargement of the airway. However, the signs of epiglottitis become worse making application of the history of the severity of the condition and the age of the child to be a mechanism for differentiating croup and epiglottitis. Additionally, asthma and epiglottitis can be differentiated in that asthma is associated with a specific trigger such as allergen exposure or a specific environmental stimulus, which may be present in the medical history of the patient while epiglottitis has no association to an environment trigger and the pattern of attack cannot be predicted (Bjornson & Johnson 2008, pp.329–339). 5. Epidemiology of epiglottitis Analysis of literature records reveals that epiglottitis has been a condition predominantly common in children aged 2-4 years. Nevertheless, the use of the Haemophilus influenza type b (Hib) vaccine has reduced the incidence of epiglottitis ( Evans & Arachman 2008, pp.320–333). Additionally, the introduction of the polysaccharide vaccine and the conjugate vaccine has increasingly helped in the reduction of the incidences of the condition. Studies conducted in the United States through a comparison made between a large US children’s hospital review from 1995 to 2003 showed a tenfold decline in the rate of admissions due to epiglottitis (Isakson & Hugosson 2011, pp.390–393). The international incidence of epiglottitis varies with a higher incidence of the condition reported in countries without universal immunization, (especially among the developing countries of Africa and Asia) (Isakson & Hugosson 2011, pp.390–393). Countries with mandatory immunization have a reported incidence of 0.9 cases per 100, 000 persons in Sweden, 0.6 and 0.8 cases per 100, 000 in the United Kingdome and Australia respectively. Inferring to the epidemiology of epiglottitis in the United Kingdome, the incidence of the condition has been recently on the rise probably due to the admission of three vaccines instead of four (McVernon et al. 2006, pp.570–572). Through a retrospective study conducted on the Danish population, the results of the study revealed that there was a national mean of 4.9 cases per 100,000 per year during the decades before admission of Hib vaccine. However, from 1996 to 2005, the introduction of the vaccine has led to a decline in the incidence of the infection to 0.02 cases per 100, 000 per year. Based on race, sex and age, recent studies indicate that epiglottitis has a higher incidence among the blacks and the Hispanics while the male gender has a higher incidence (60%) of contracting the condition (McEwan et al. 2003). Inferring to the age, epiglottitis is common among the children as compared to adults. Adult presentation with epiglottitis may resemble an upper respiratory tract infection with unexplained sore throat and tenderness of the anterior neck (Guldfred et al. 2008, pp.818–823). 6. Pathophysiology of epiglottitis Epiglottitis results from bacterial infection of the epiglottis. The most common bacteria causing the inflammation of epiglottis is Haemophilus influenza type B, however, some cases of the condition are attributed to staphylococcus pneumonia, Streptococcus agalactia, streptococcus pyogenes (Bessen 2009, pp.581–593), Staphylococcus aureus, Moraxella catarrhalis and Haemophilus influenza. Additionally, physical injury could be another mechanism resulting to epiglottitis. A direct blow to the throat and burns from drinking a very hot liquid can cause the condition. As a result of bacterial infection, there is an inflammation of the epiglottis resulting in erythema and pain. This is responsible for the referred pain in the ear, noted as earache and pain to the head noted as headache as noted in the case study. Inflammation of the epiglottis results to swelling of which restricts modality of the structure impairing its function of closing and opening the windpipe during eating episodes (Abdallah 2012, p.279). The impairment of the function of the epiglottis-preventing opening of the windpipe makes the work of breathing difficult thus causing the use of excess force during inspiration and expiration resulting to stridor and wheezing (Sobol & Zapata 2008). Due to impairment of the respiratory process, the respiratory rate is increased as the respirations are made shallow gasps that are insufficient for effective gaseous exchange (Sobol & Zapata 2008). Lack of effectiveness in gaseous exchange leads to poor perfusion of tissues, which is evidenced by cyanosis and delayed capillary refill. In response to poor tissue perfusion, the heart rate increases in an attempt to increase blood supply to tissues. The increase in heart rate would thus be indicated as a sinus tachycardia in the electrocardiogram (Sobol & Zapata 2008, pp.551–566). Bacterial infection resulting to epiglottitis would lead to an anti-inflammatory response by the white blood cells resulting in elevation of body temperature that is evidenced by increased temperature on palpation, sweating, and palpitation (Guldfred et al. 2008, pp.818–823). Due to the swelling and inflammation of epiglottis, the patient will experience dysphagia due to the pain experienced through the bruising action of the food as it passes the epiglottis, this would equally lead to nausea and vomiting. The symptoms of the condition are less server when the patient is in a sitting position since the epiglottis covers less of the trachea increasing chances of gracious exchange, while in a lying position; the epiglottis covers the windpipe increasing the symptoms of the condition (Guldfred et al. 2008, pp.818–823). 7. Complications of epiglottitis Epiglottitis can be a dangerous condition if there is a complete blockage of the airway, and emergency treatment is not effectively offered (Buttaro, T. M. 2013, pp. 390-395). Despite deaths from epiglottitis being rare, in some cases, infection of the epiglottis can spread to nearby body parts causing secondary infections. Infection of the epiglottis can spread laterally resulting to infection of the middle ear resulting in otitis media (Buttaro, T. M. 2013 , pp. 390-395). Ascending of the bacterial infection from the epiglottis to the brain can cause meningitis while descending of the infectious bacteria from the epiglottis to the heart lining and the lungs can cause pericarditis and pneumonia respectively (Buttaro, T. M. 2013, pp. 390-395). Otitis media is an inflammation of the middle ear as a result of bacterial infection. Infection of the epiglottis can result in otitis media by the transmission of the bacteria through the Eustachian tube to the middle ear (Rovers 2008, pp. 23-39). Epiglottitis can complicate either to acute otitis media or otitis media with effusion depending on the type of the causative bacteria. Acute otitis media infection is abrupt in onset and presents with ear pain as witnessed in the case of Ryan. The symptoms of the condition could also be decreased eating, poor sleeping and fever. On the other hand, otitis media with effusion presents without symptoms except feeling of fullness of the ear (Rovers 2008, pp. 23-39). Meningitis is an inflammation of the meninges of the brain and the spinal cord. The condition can occur as a compilation of epiglottitis as a form of ascending infection. Early symptoms of the condition can be mistaken for an influenza, but the signs of the condition develop over several hours to include stiffness of the neck, fever, vomiting, server headache, seizure sensitivity to light and confusion (Nesseler et al. 2010, pp.1346–1347). Bacteria causing epiglottitis can be transmitted via the blood stream to the pericardium resulting to pericarditis (Syed et al. 2013, pp.277–287). Pericarditis is thus the swelling and the irritation of the pericardium of the heart. Pericarditis often results in sharp chest pain that occurs as a result of the pericardium rubbing against each other. Most cases of pericarditis are mild and improve on their own; however, pericarditis resulting from the complication of epiglottitis is resolved through treatment with antibiotics. Additionally, early diagnosis and treatment of the condition is crucial for the reduction of the risk of long-term complication from pericarditis (Pankuweit et al. 2005, pp.103–112). Pneumonia is an inflammation of the alveoli that can result from the complication of epiglottitis. Dislodgement of the bacteria causing the inflammation of epiglottis through the airway to the lungs can result in pneumonia. As a result of bacterial infection to the lungs, the alveoli may fill with fluid or pus causing productive cough, fever, dyspnea, and chills. Pneumonia symptoms can be mild, or life threatening and the symptoms are more serious among the children due to weaker immunity (Nair & Niederman 2013, pp.521–546). 8. Pre-hospital management of epiglottitis The basic concern for the treatment of a person with epiglottitis is the management of the airway, since the condition can become life threatening especially among the children. In paramedics, maintenance of the airway and provision of rapid transportation of the patient to a health facility are the two main goals in the management of epiglottitis in a pre-hospital setting according to the Australian emergency management guidelines. However, the initial assessment of the patient can be done, which include an assessment of the airway, breathing and circulation, which can be done through history taking. The primary approach to pediatric airway management in a pre-hospital setting includes; positioning of the head, examination of the airway and maintenance of oxygen saturation through the administration of supplemental oxygen (Donaldson et al. 2004, pp.155–161). A child suffering from epiglottitis may not be willing to move from their current position, thus moving them against their will would increase anxiety to the child and lead to complete airway obstruction. Any intervention that causes anxiety to the child like repositioning and attempt to examine the airway with the spatula should be avoided (Donaldson et al. 2004, pp.155–161). When managing a case of epiglottitis in a pre-hospital setup, an attempt to intubating the patient should be avoided unless the condition results to acute airway obstruction ( Bluestone, C. 2003, pp. 1599-1600). The process of intubation would result in pain, which may increase anxiety causing a complete airway obstruction in children. Based on the grading of epiglottitis, an unstable patient with extreme condition requires immediate airway management. Signs and symptoms associated with the need for intubation, in this case, include compromised the airway, respiratory distress, stridor, sitting erect, drooling and inability to swallow. Stable patients without signs of airway compromise, dyspnea, stridor or drooling may be managed without the need of immediate airway intervention. However, due to the rapidity with which compromise in the airway may occur, continuous evaluation should be conducted as the patient is transported to a health care facility (Townsend & Luck, 2013). During the management of the patient in a pre-hospital setup, consideration should be taken to avoid agitating the patient. The patient should be left to assume a position that is most comfortable. Orotracheal intubation may be required within a little warning. Thus, the equipment for intubation like cricothyroidotomy or a needle jet ventilation should be available at the bedside (Sakles et al. 2013). Therapies such as sedation of the patient and inhalers should be avoided, as they have no effect on the management of epiglottitis. When managing a patient who is not experiencing server signs of epiglottitis, management of a perceived complication to respiratory failure could include interventions like administration of oxygen using a slow ventilation sequence by bag valve mask. A needle cricothyroidotomy should only be done after the failure of a slow ventilation sequence by bag valve mask. When a paramedic is anticipating the worsening of the condition basing from the history, intubation may be necessary since intubation is difficult in server cases of epiglottitis in children, thus it should be done as soon as possible (So et al. 2006, pp.344–347). In the management of the case, the basic management principles should be considered. Principles of the safety of the scene should be considered to ensure that both the patient and the paramedic are same from any environmental harm. A paramedic should consider suctioning when drooling is present in a bid to maintain the patency of the airway. In circulation, the circulatory process should be monitored, and cannulation avoided especially when it causes anxiety to the patient (Hicks et al. 2010, pp.1127–1139). For effective management of epiglottis, effective communication should be maintained between the paramedic, the patient, and the parents. A paramedic should communicate with the patient before performing any intervention like bagging or intubating. Additionally, the parents should be reassured all the time to keep them and the patient as calm as possible. Rapid transportation of the patient to the hospital is recommended to enable management of the patient in case of a respiratory arrest. If the time to the nearest hospital is considerable, a paramedic should sort for a backup while constantly monitoring the patient. 9. Conclusion Caring for a child with an emergency respiratory condition can be challenging and scary. However, when a paramedic can recognize the diagnosis of the problem, the management of the problem can be simpler and could help in saving a life. To effectively diagnose a condition, a paramedic mist use differential diagnosis to rule out other likely conditions to be able to target the specific condition causing the respiratory problem. Epiglottis is common in children especially those who have hospitalized, hence thorough assessment should be conducted and implementation done to prevent complication of the condition. A paramedic must always remember the significance of management of the airway and rapid transportation to a health care facility as essential elements in the management of epiglottis. 10. Bibliography Abdallah, C., 2012. Acute epiglottitis: Trends, diagnosis and management. Saudi Journal of Anaesthesia, 6, p.279. Bessen, D.E., 2009. Population biology of the human restricted pathogen, Streptococcus pyogenes. Infection, Genetics and Evolution, 9, pp.581–593. Bjornson, C.L. & Johnson, D.W., 2008. Croup. Lancet, 371, pp.329–339. Bluestone, C. D. (2003). Pediatric otolaryngology. 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