Croup+Diphtheria+ Ac.Epiglottitis


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one of the commonest ent disease

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Croup+Diphtheria+ Ac.Epiglottitis

  1. 1. (Croup) Laryngotracheobronchitis <ul><li>Mean age 18/12 month. </li></ul><ul><li>Boys more affected. </li></ul><ul><li>Causative organism. </li></ul><ul><ul><li>Para-influenza virus type I. </li></ul></ul><ul><ul><li>Para-influenza virus type II. </li></ul></ul><ul><ul><li>Para-influenza virus type III. </li></ul></ul><ul><ul><li>Influnza virus type A. </li></ul></ul><ul><ul><li>Respiratory syncyteal virus. </li></ul></ul><ul><ul><li>Rhinovirus. </li></ul></ul><ul><li>Not uncommon for secondary Bacterial infection to supervene. </li></ul>
  2. 2. <ul><li>Clinical picture: </li></ul><ul><ul><li>Always preceded by U.R.T. I. </li></ul></ul><ul><ul><li>Hoarseness of voice. </li></ul></ul><ul><ul><li>Croupy cough (Musical cough) (Bark of a seal). </li></ul></ul><ul><ul><li>Strider initially inspirotary then Biphasic (due to subglottic oedema). </li></ul></ul><ul><ul><li>Pyrexia. </li></ul></ul><ul><ul><li>Flairing of ala nasae. </li></ul></ul><ul><ul><li>Suprasternal and intercostal recession. </li></ul></ul><ul><li>Management of croup </li></ul><ul><li>Radiology </li></ul><ul><ul><li>Neck X-ray </li></ul></ul><ul><ul><li>Chest X-ray (Steeple sign) </li></ul></ul><ul><ul><li>May need alternative airway 1%. </li></ul></ul><ul><ul><li>Provided epigloltitis is unlikely then conservative management. </li></ul></ul>Lateral A.P
  3. 3. <ul><li>Observation: </li></ul><ul><li>Stridor – lessening </li></ul><ul><li>Restlessness </li></ul><ul><li>Color </li></ul><ul><li>Respiratory rate </li></ul><ul><li>Cardiac rate </li></ul><ul><li>Reassurance </li></ul><ul><li>Not to separate the child from parents. </li></ul><ul><li>Sedation of essential, chloral hydrate 30 mg/ Kg. </li></ul><ul><li>Humidification: </li></ul><ul><li>warm most air (tent) prevent drying of secretions ideal situation is a (croup room). </li></ul><ul><li>Hydration orally or I.V </li></ul><ul><li>Oxygen: </li></ul><ul><ul><li>Pulse oxymetery oxygen given based on oxygen saturation. </li></ul></ul><ul><li>Steroids: </li></ul><ul><li>As a last resort to resuscitate a child dexametha 0.6 mg/ Kg as a single dose. </li></ul>
  4. 4. <ul><li>ABI: </li></ul><ul><ul><li>When 2ndy bacterial infection supervene </li></ul></ul><ul><ul><li>For intubate patients. </li></ul></ul><ul><li>Rasemic adrenaline: </li></ul><ul><ul><li>- Diluted with saline. </li></ul></ul><ul><ul><li>Nebulized. </li></ul></ul><ul><ul><li>At hospital. </li></ul></ul><ul><ul><li>0.25 ml of 2.25%. </li></ul></ul><ul><ul><li>ECG monitoring. </li></ul></ul><ul><li>Combination of: </li></ul><ul><ul><li>Falling pulse rate. </li></ul></ul><ul><ul><li>Relaxation of restless child. </li></ul></ul><ul><ul><li>Quietening of stridor. </li></ul></ul><ul><ul><li>Maintenance of good colour. </li></ul></ul><ul><ul><li>Suggests favourable progress. </li></ul></ul>
  5. 5. Diphtheria <ul><li>Rare when immunization is the rule. </li></ul><ul><li>Laryngeal diphtheria nearly always follows pharyngeal infection. </li></ul><ul><li>Causative organism is corynebacterium diphtheriae 3 strains (gravis – intermedius mitis). Nearly always it is the gravis strain responsible from major epidermics. </li></ul><ul><li>Mortality due to: </li></ul><ul><ul><li>Laryngeal obstruction. </li></ul></ul><ul><ul><li>Production of endotoxin: </li></ul></ul><ul><ul><ul><li>i- Myocarditis. </li></ul></ul></ul><ul><ul><ul><li>ii- Peripheral neuritis. </li></ul></ul></ul><ul><li>Initial lesion in region of tonsills grey membrane is formed bleeds in attempt to remove. </li></ul><ul><li>Bull neck due to cellulitis and regional lymphodenapathy. </li></ul>
  6. 6. <ul><li>Clinical features: </li></ul><ul><ul><li>Onset is insidious. </li></ul></ul><ul><ul><li>Barking cough. </li></ul></ul><ul><ul><li>Stridor. </li></ul></ul><ul><ul><li>Chest wall recession. </li></ul></ul><ul><ul><li>Malaise. </li></ul></ul><ul><ul><li>Pyrexia. </li></ul></ul><ul><ul><li>Sore throat. </li></ul></ul><ul><ul><li>Membrane over the faucial pillars. </li></ul></ul><ul><ul><li>Toxaemia. </li></ul></ul><ul><ul><li>Dysphagia prior to laryngeal involvement. </li></ul></ul><ul><ul><li>Myocarditis during the second week of the disease. </li></ul></ul><ul><ul><li>Palatal paralysis with nasal regurgitation of food and nasal escape to the voice. </li></ul></ul>
  7. 7. Management: <ul><li>Penicillin. </li></ul><ul><li>Antitoxin 10.000/ 100.000 unit. </li></ul><ul><li>Conservative therapy. </li></ul><ul><ul><li>Humidification. </li></ul></ul><ul><ul><li>Oxygen. </li></ul></ul><ul><ul><li>If failed-remove the membrane from the larynx with intubation. </li></ul></ul><ul><li>Bed rest for 2-4 weeks (danger of myocarditis). </li></ul>
  8. 8. Acute epiglottitis <ul><li>Causative organism: </li></ul><ul><ul><li>Heamophilus influnzae (type B) commonest. </li></ul></ul><ul><ul><li>B hermolytic streptococcus. </li></ul></ul><ul><ul><li>Pnemococcus. </li></ul></ul><ul><ul><li>Staphylococcus. </li></ul></ul><ul><li>More common in winter months. </li></ul><ul><li>Most cases seen in children between 1-6 years (peak 3-4). </li></ul><ul><li>In contrast to croup which affects younger children (peak 18 month). </li></ul><ul><li>Occationally seen in adult. </li></ul>
  9. 9. Clinical features: <ul><ul><li>Sore throat. </li></ul></ul><ul><ul><li>½ hour later dysphegia. </li></ul></ul><ul><ul><li>Inspiratory stridor (within 2 hours) critically ill patient. </li></ul></ul><ul><ul><li>Sitting up and learning forward. </li></ul></ul><ul><ul><li>If he lie back soffocation may occur (the epiglottis may occlude the larynx) and using his arm to fix his chest wall in order to use the accessory muscles of respiration. </li></ul></ul><ul><li>Dribbling of saliva will be prefuse due to dysphgia. </li></ul><ul><li>Voice is muffled. </li></ul><ul><li>Inspiratory stridor. </li></ul><ul><li>As time passes the child becomes quite and floppy due to extreme fatigue indicates respiratory and cardiac arrest are imminent. </li></ul><ul><li>Frieghtent child. </li></ul><ul><li>Pyrexia shock and paller. </li></ul><ul><li>Cervical lymphadenopathy. </li></ul><ul><li>Don’t examine the pharynx. </li></ul>
  10. 10. Management: <ul><li>If the child thought to have epiglottitis. </li></ul><ul><li>Comfort the terrified child. </li></ul><ul><li>Don’t restrain the child as not to cause him crying and precipitate obstruction. </li></ul><ul><li>Radiology not advised though lateral neck X-ray may show (thumb) sign if the child condition permit and it is available at emergency room and there is doubt about diagnosis. </li></ul><ul><li>The child is carried to resuscitation room by his mother. </li></ul><ul><li>Anaesthetic, otolaryngological and pediatric staff will prepare to secure an alternative airway. </li></ul><ul><li>Anaesthesia is introduced in upright position. </li></ul>
  11. 11. <ul><li>If the child collapse prior to anesthesia intubation or bronchoscope without delay and without induction of anesthesia. </li></ul><ul><ul><li>If failed rigid bronchoscope followed by tracheostomy. </li></ul></ul><ul><ul><li>Muscle relaxants are not used. </li></ul></ul><ul><ul><li>Avoid intravenous anesthesia induction. </li></ul></ul><ul><ul><li>Patient is in lateral semi-pron position. </li></ul></ul><ul><ul><li>Use semi-sold introducer. </li></ul></ul>
  12. 12. <ul><ul><li>If entrance of laryngeal inlet is not obvious sudden compression of the child chest will produce bubble of air in mucous. </li></ul></ul><ul><ul><li>If intubation failed introduce bronchoscope and may followed by tracheostomy at this stage. </li></ul></ul><ul><ul><li>Take culture swab from epiglottis. </li></ul></ul><ul><ul><li>Blood culture sample. </li></ul></ul><ul><ul><li>I.V infusion line for: </li></ul></ul><ul><ul><ul><li>Replacement. </li></ul></ul></ul><ul><ul><ul><li>ABI (Chloramphnicol or Cefotaxime, Cefuroxime ). </li></ul></ul></ul><ul><ul><li>Keep patient at I.C.U. </li></ul></ul><ul><ul><li>Sedation before transfer to I.C.U. </li></ul></ul><ul><ul><li>Extubation within 48 hours </li></ul></ul>