12-phase flow (12)

1. 1FRAME
   Confirm acute epiglottitis / supraglottitis scope (airway emergency, any pediatric age); exclude croup / bacterial tracheitis / retropharyngeal-peritonsillar abscess / foreign body / anaphylaxis-angioedema / diphtheria as the dominant diagnosis (AAP Red Book 2024-2025)
   inputs: age
   advance: Airway-emergency framing confirmed; mimics noted
2. 2ENTRY
   Trigger captured: tripod + drooling + muffled voice + stridor + toxic appearance, OR thermal/caustic exposure with airway symptoms — recognized WITHOUT provoking the child (pediatric airway-emergency literature)
   inputs: age, drooling, stridor
   advance: Entry trigger captured non-invasively
3. 3CONTEXT
   Hib immunization status (primary etiologic-prior modifier), immunocompromise, thermal/caustic exposure history, symptom-onset tempo, vitals, meds/allergies — collected WITHOUT agitating the child (no exam, no IV, no supine) (AAP Red Book 2024-2025)
   inputs: hib_immunization_status, symptom_onset_tempo, thermal_caustic_exposure, temperature, hr, current_meds_and_allergies
   advance: Context captured non-invasively
4. 4RED_FLAGS
   IMPENDING AIRWAY OBSTRUCTION: tripod posture, drooling, stridor at rest, "sniffing" position, agitation → fatigue / quiet child, SpO2 drop, bradycardia (pre-arrest) → DEFER throat exam, KEEP CHILD CALM with caregiver, activate the most experienced airway operator + ENT + anesthesia NOW; surgical-airway backup prepped (pediatric airway-emergency literature)
   inputs: drooling, stridor, work_of_breathing, mental_status, spo2
   actions: workup.pediatric_fever
   advance: Senior airway team activated OR impending-obstruction red flags excluded
5. 5INITIAL_WORKUP
   AIRWAY-FIRST: NO venipuncture / NO supine / NO tongue-blade throat exam until the airway is secured. Lateral neck radiograph ("thumbprint sign") ONLY if the child is stable + the airway is not in immediate jeopardy — render imaging inline; never send the child unaccompanied; a normal film does NOT exclude. Blood + epiglottic surface cultures are obtained in the OR AFTER the airway is secured (pediatric airway-emergency literature)
   inputs: stridor, spo2, lateral_neck_radiograph_thumbprint
   actions: workup.pediatric_fever
   advance: Airway secured OR stable + lateral neck imaging obtained
6. 6BRANCHING_WORKUP
   AFTER airway secured: blood culture + epiglottic surface culture + CBC + renal panel (vancomycin dosing); neck CT only if abscess suspected AND airway protected; thermal/caustic → toxicology + burn + inhalation-injury assessment (IDSA; AAP Red Book 2024-2025)
   inputs: blood_culture, epiglottic_surface_culture, thermal_caustic_exposure, neck_ct_if_abscess_and_airway_protected
   actions: workup.aspiration_pneumonia
   advance: Post-airway diagnostics obtained as triggered
7. 7DIFFERENTIAL
   Epiglottitis vs croup (subglottic, barky cough, gradual) vs bacterial tracheitis (brassy cough, toxic, pseudomembrane) vs retropharyngeal / peritonsillar abscess vs foreign body vs anaphylaxis / angioedema vs diphtheria — pivot findings: muffled "hot-potato" voice + drooling + tripod + abrupt onset favor epiglottitis; absence of barky cough shifts away from croup (AAP Red Book 2024-2025; pediatric airway-emergency literature)
   inputs: muffled_hot_potato_voice, drooling, stridor
   advance: Dominant diagnosis assigned
8. 8RISK_STRATIFICATION
   Airway trajectory: impending obstruction (tripod, drooling, stridor at rest, sniffing, agitation→fatigue) vs stable (toxic but maintaining airway, no stridor at rest, willing to lie back) — drives immediate-OR vs controlled-environment timing. pSOFA / qSOFA only as a SEPSIS adjunct AFTER airway secured — NEVER for airway timing (airway timing is clinical, not calculator-driven) (pediatric airway-emergency literature)
   inputs: work_of_breathing, mental_status, spo2
   advance: Airway trajectory + timing set
9. 9TREATMENT
   AIRWAY MANAGEMENT FIRST: controlled OR intubation by the MOST EXPERIENCED operator with ENT + anesthesia present, spontaneous-ventilation inhalational induction (sevoflurane), smaller-than-predicted ETT, NO neuromuscular blockade until the airway is visualized, rigid bronchoscopy immediately available, surgical-airway backup (age-dependent needle vs surgical cricothyrotomy; tracheostomy) prepped; bag-mask ventilation as a bridge if sudden complete obstruction. THEN empiric IV antibiotics AFTER airway secured: ceftriaxone 50-100 mg/kg/day IV (or cefotaxime 150-200 mg/kg/day IV q6-8h if <1 mo / ceftriaxone contraindicated) ± vancomycin 60-80 mg/kg/day IV q6-8h (AUC 400-600) if MRSA risk; 7-10 d total. Adjuncts: dexamethasone (limited evidence), nebulized epinephrine ONLY as a controlled bridge (never a substitute for / reason to delay definitive airway). Thermal/caustic → airway management is the treatment; antibiotics NOT primary (AAP Red Book 2024-2025; IDSA; pediatric airway-emergency literature)
   inputs: age, weight, spo2
   advance: Airway secured + empiric regimen + adjunct plan documented
10. 10DISPOSITION
    PICU for ALL (intubated airway); OR → PICU; surgical airway → PICU; thermal/caustic → PICU ± burn unit; never discharge a child with stridor + drooling + toxic appearance without airway clearance (pediatric airway-emergency literature)
    inputs: spo2
    advance: Disposition (PICU) documented
11. 11MONITORING
    Secured-tube + sedation monitoring, continuous SpO2 + capnography, daily supraglottic-edema / air-leak assessment, antibiotic response, accidental-extubation contingency (re-intubation / surgical-airway capability at bedside) (pediatric airway-emergency literature; IDSA)
    inputs: spo2
    advance: Air-leak development + clinical improvement documented
12. 12FOLLOWUP
    Extubate in a controlled setting when supraglottic edema resolves + an air-leak develops (typically 24-72 h); complete 7-10 d antibiotics; rifampin chemoprophylaxis of household / childcare contacts if Hib confirmed with an under-immunized vulnerable contact (AAP Red Book 2024-2025); Hib + routine immunization catch-up (natural disease may not confer protection); ENT follow-up (AAP Red Book 2024-2025; IDSA)
    advance: Extubation + contact prophylaxis + immunization catch-up plan documented