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peds.epiglottitis.v1PRODUCTION
peds.epiglottitis.v1

Pediatric Acute Epiglottitis (Supraglottitis)

pediatricsacutepediatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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Advance rule
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Airway-emergency framing confirmed; mimics noted

Patient inputs (19)

Epiglottitis can occur at any pediatric age; peak shifted post-Hib vaccine; <1 yr rare but possible (AAP Red Book 2024-2025)

Primary etiologic-prior modifier — fully Hib-vaccinated shifts away from Hib toward S. pyogenes / S. aureus / S. pneumoniae; unvaccinated re-elevates Hib (AAP Red Book 2024-2025)

Scald / steam / smoke / caustic ingestion / vapor inhalation — non-infectious supraglottitis; airway is the treatment, antibiotics NOT primary (pediatric airway-emergency literature)

Abrupt onset + rapid progression over hours favors epiglottitis vs the more gradual croup prodrome (AAP Red Book 2024-2025)

Tachycardia from distress; bradycardia = pre-arrest in obstruction (pediatric airway-emergency literature)

High fever + toxic appearance supports bacterial supraglottitis (AAP Red Book 2024-2025)

β-lactam allergy severity drives ceftriaxone/cefotaxime vs alternative; baseline meds for sedation interactions (IDSA)

Muffled "hot-potato" voice (NOT barky cough) = supraglottic vs subglottic pivot (pediatric airway-emergency literature)

Drooling + dysphagia = supraglottic obstruction; component of the triad (LR+ aggregate ≈ 15-25 with tripod + stridor vs croup) (pediatric airway-emergency literature)

Inspiratory stridor at rest = significant upper-airway narrowing; impending-obstruction red flag (pediatric airway-emergency literature)

Retractions / accessory use / "sniffing" position — severity + airway trajectory (pediatric airway-emergency literature)

Agitation → fatigue / quiet child = PRE-ARREST pivot (escalates impending → obstruction now) (pediatric airway-emergency literature)

SpO2 drop is a LATE sign — do not wait for desaturation to secure the airway (pediatric airway-emergency literature)

All antibiotic + ETT + adjunct dosing is weight-based (mg/kg) (IDSA)

Drawn in the OR AFTER the airway is secured — never before (pediatric airway-emergency literature)

Obtained in the OR at the time of airway control to direct narrowing (IDSA)

Neck CT only if abscess suspected AND airway already protected (IDSA)

Immunocompromise re-elevates Hib + broadens bacterial differential despite vaccination (AAP Red Book 2024-2025)

Lateral neck XR "thumbprint sign" ONLY if stable + airway not jeopardized; never delay airway control; normal film does NOT exclude (pediatric airway-emergency literature)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningimpending_airway_obstruction_epiglottitis
    Tripod posture + drooling + stridor at rest + muffled "hot-potato" voice + toxic appearance + "sniffing" position — impending complete airway obstruction (AAP Red Book 2024-2025; pediatric airway-emergency literature)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpre_arrest_airway_obstruction
    Agitation → fatigue / quiet child / falling SpO2 / bradycardia — pre-arrest, obstruction imminent or occurring (pediatric airway-emergency literature)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningthermal_caustic_supraglottitis
    Hot-liquid scald / steam / smoke inhalation / caustic ingestion / vapor inhalation with progressive supraglottic edema — non-infectious supraglottitis (pediatric airway-emergency literature)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremrsa_risk_severe_epiglottitis
    Severe / toxic epiglottitis with MRSA risk — local CA-MRSA prevalence, prior MRSA, abscess / collection, or thermal injury with secondary infection (AAP Red Book 2024-2025; IDSA)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereunvaccinated_hib_epiglottitis
    Unvaccinated / under-vaccinated / vaccine-failure / immunocompromised child with bacterial epiglottitis — Hib etiologic prior re-elevated (AAP Red Book 2024-2025)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestable_but_toxic_uncertain_diagnosis
    Toxic but maintaining the airway, no stridor at rest, diagnosis uncertain — stable branch (pediatric airway-emergency literature)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Airway management FIRST — keep child calm, defer exam, controlled OR intubation by most experienced operator (ENT + anesthesia), surgical-airway backup; NO supine / NO IV / NO throat exam until airway plan ready (AAP Red Book 2024-2025; pediatric airway-emergency literature)
axis: peds_epiglottitis_airway_management
Selected axis "Airway management FIRST — keep child calm, defer exam, controlled OR intubation by most experienced operator (ENT + anesthesia), surgical-airway backup; NO supine / NO IV / NO throat exam until airway plan ready (AAP Red Book 2024-2025; pediatric airway-emergency literature)" by default fallback (first axis)
  • keep child calm with caregiver — defer throat exam, no supine, no IV, no agitation
    first line
    airway_protection_non_pharm
    Child upright in position of comfort on caregiver lap; minimal handling; supplemental humidified O2 blow-by only if tolerated without distress • supportive • continuous until controlled airway
    triggers: suspected_epiglottitis_unprotected_airway
    Agitation / tongue-blade exam / supine positioning can precipitate complete obstruction (pediatric airway-emergency literature)
  • activate most experienced airway operator + ENT + anesthesia; prep rigid bronchoscopy + surgical-airway backup
    first line
    airway_team_activation_non_pharm
    Senior anesthesiologist + otolaryngologist to OR; difficult-airway cart, rigid bronchoscope, age-appropriate cricothyrotomy / tracheostomy set ready • system • immediate on suspicion
    triggers: impending_airway_obstruction, classic_triad_in_toxic_child
    Definitive airway should be secured electively before obstruction by the most experienced operator (pediatric airway-emergency literature)
  • controlled OR endotracheal intubation — spontaneous-ventilation inhalational induction (sevoflurane), smaller-than-predicted ETT, NO paralysis until airway visualized
    first line
    definitive_airway_non_pharm
    Sevoflurane inhalational induction maintaining spontaneous ventilation; ETT 0.5-1.0 size smaller than predicted; confirm placement; secure • procedure • definitive (single controlled procedure)
    triggers: airway_team_assembled_in_or
    Spontaneous-ventilation inhalational technique preserves the airway during instrumentation; paralysis before visualization risks an unrescuable airway (pediatric airway-emergency literature)
  • bag-mask ventilation bridge then emergent surgical airway (needle vs surgical cricothyrotomy age-dependent; tracheostomy)
    rescue
    rescue_airway_non_pharm
    BMV with two-person technique + airway adjuncts as a bridge; if cannot intubate / cannot oxygenate → age-appropriate surgical airway by the most experienced operator • procedure • rescue if sudden complete obstruction
    triggers: complete_obstruction_before_controlled_airway, cannot_intubate_cannot_oxygenate
    BMV is frequently effective as a bridge in epiglottitis; surgical airway is the final rescue (pediatric airway-emergency literature)

ed playbook — drug actions (4)

  1. 1. keep child calm with caregiver — NO throat exam, NO supine, NO IV, blow-by humidified O2 only if tolerated
    position of comfort • supportive • continuous
    trigger: Suspected epiglottitis, unprotected airway
    Agitation precipitates obstruction (pediatric airway-emergency literature)
  2. 2. activate most experienced airway operator + ENT + anesthesia; prep OR + rigid bronchoscopy + surgical-airway backup
    system activation • system • immediate
    trigger: Classic triad in toxic child OR any impending-obstruction red flag
    Elective controlled airway before obstruction (pediatric airway-emergency literature)
  3. 3. lateral neck radiograph (thumbprint sign) — ONLY if stable + airway not jeopardized, child accompanied
    single film, render inline • imaging • once if stable
    trigger: Diagnosis uncertain AND child stable AND airway not in jeopardy
    Never delay airway control; normal film does NOT exclude (pediatric airway-emergency literature)
  4. 4. empiric IV antibiotics — ceftriaxone (or cefotaxime <1 mo) ± vancomycin if MRSA risk — AFTER airway secured
    rxcui 2193
    ceftriaxone 50-100 mg/kg/day IV • IV • daily or q12-24h
    trigger: Airway secured (OR/intubated)
    AAP Red Book 2024-2025 + IDSA — covers H. influenzae + S. pneumoniae + S. pyogenes

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Tripod posture + drooling + toxic appearance in a febrile child — recognize from across the room (AAP Red Book 2024-2025; pediatric airway-emergency literature); Inspiratory stridor at rest + muffled "hot-potato" voice (NOT barky cough) (pediatric airway-emergency literature); Refusal to swallow + rapid symptom progression over hours (AAP Red Book 2024-2025).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric Acute Epiglottitis (Supraglottitis)** (peds.epiglottitis.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Airway management FIRST — keep child calm, defer exam, controlled OR intubation by most experienced operator (ENT + anesthesia), surgical-airway backup; NO supine / NO IV / NO throat exam until airway plan ready (AAP Red Book 2024-2025; pediatric airway-emergency literature)**.
1. keep child calm with caregiver — defer throat exam, no supine, no IV, no agitation Child upright in position of comfort on caregiver lap; minimal handling; supplemental humidified O2 blow-by only if tolerated without distress supportive continuous until controlled airway (airway_protection_non_pharm, first line) — Agitation / tongue-blade exam / supine positioning can precipitate complete obstruction (pediatric airway-emergency literature)
2. activate most experienced airway operator + ENT + anesthesia; prep rigid bronchoscopy + surgical-airway backup Senior anesthesiologist + otolaryngologist to OR; difficult-airway cart, rigid bronchoscope, age-appropriate cricothyrotomy / tracheostomy set ready system immediate on suspicion (airway_team_activation_non_pharm, first line) — Definitive airway should be secured electively before obstruction by the most experienced operator (pediatric airway-emergency literature)
3. controlled OR endotracheal intubation — spontaneous-ventilation inhalational induction (sevoflurane), smaller-than-predicted ETT, NO paralysis until airway visualized Sevoflurane inhalational induction maintaining spontaneous ventilation; ETT 0.5-1.0 size smaller than predicted; confirm placement; secure procedure definitive (single controlled procedure) (definitive_airway_non_pharm, first line) — Spontaneous-ventilation inhalational technique preserves the airway during instrumentation; paralysis before visualization risks an unrescuable airway (pediatric airway-emergency literature)
4. bag-mask ventilation bridge then emergent surgical airway (needle vs surgical cricothyrotomy age-dependent; tracheostomy) BMV with two-person technique + airway adjuncts as a bridge; if cannot intubate / cannot oxygenate → age-appropriate surgical airway by the most experienced operator procedure rescue if sudden complete obstruction (rescue_airway_non_pharm, rescue) — BMV is frequently effective as a bridge in epiglottitis; surgical airway is the final rescue (pediatric airway-emergency literature)

Setting playbook (ed) — Recognize the airway emergency from across the room; KEEP THE CHILD CALM; defer the throat exam; activate the most experienced airway operator + ENT + anesthesia; move to a controlled environment (OR) for definitive airway BEFORE obstruction (AAP Red Book 2024-2025; pediatric airway-emergency literature)
5. keep child calm with caregiver — NO throat exam, NO supine, NO IV, blow-by humidified O2 only if tolerated position of comfort supportive continuous — Suspected epiglottitis, unprotected airway (Agitation precipitates obstruction (pediatric airway-emergency literature))
6. activate most experienced airway operator + ENT + anesthesia; prep OR + rigid bronchoscopy + surgical-airway backup system activation system immediate — Classic triad in toxic child OR any impending-obstruction red flag (Elective controlled airway before obstruction (pediatric airway-emergency literature))
7. lateral neck radiograph (thumbprint sign) — ONLY if stable + airway not jeopardized, child accompanied single film, render inline imaging once if stable — Diagnosis uncertain AND child stable AND airway not in jeopardy (Never delay airway control; normal film does NOT exclude (pediatric airway-emergency literature))
8. empiric IV antibiotics — ceftriaxone (or cefotaxime <1 mo) ± vancomycin if MRSA risk — AFTER airway secured ceftriaxone 50-100 mg/kg/day IV IV daily or q12-24h — Airway secured (OR/intubated) (AAP Red Book 2024-2025 + IDSA — covers H. influenzae + S. pneumoniae + S. pyogenes)

Non-pharmacologic actions:
- Do NOT examine the oropharynx with a tongue blade in the unprotected airway (pediatric airway-emergency literature)
- Do NOT place the child supine or force position changes (pediatric airway-emergency literature)
- Do NOT obtain IV access or venipuncture until the airway plan is ready (pediatric airway-emergency literature)
- Transport to OR accompanied by the airway operator with a bag-mask + surgical-airway kit (pediatric airway-emergency literature)
- Thermal/caustic exposure → airway management is the treatment; antibiotics not primary; toxicology + burn consult (pediatric airway-emergency literature)

AVOID / contraindication checks:
- Do_not_examine_oropharynx_with_tongue_blade_in_unprotected_airway (pediatric airway emergency literature)
- Do_not_place_child_supine_until_airway_secured (pediatric airway emergency literature)
- Do_not_obtain_iv_or_venipuncture_until_airway_plan_ready_no_agitation (pediatric airway emergency literature)
- No_neuromuscular_blockade_until_airway_directly_visualized (pediatric airway emergency literature)
- Never_send_child_unaccompanied_to_radiology (pediatric airway emergency literature)
- Imaging_must_never_delay_airway_control_normal_film_does_not_exclude (pediatric airway emergency literature)

Monitoring

Regimen monitoring:
- continuous observation with airway operator at bedside until secured (pediatric airway-emergency literature)
- continuous spo2 pulse oximetry minimal handling (pediatric airway-emergency literature)
- capnography after intubation (pediatric airway-emergency literature)
- do not leave child unattended until airway secured (pediatric airway-emergency literature)

Setting (ed) monitoring:
- Continuous SpO2 + observation with the airway operator at bedside (pediatric airway-emergency literature)
- Reassess airway trajectory continuously — do not leave the child unattended (pediatric airway-emergency literature)

Follow-up plan: 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)
- Close-out criterion: Extubation + contact prophylaxis + immunization catch-up plan documented

Monitoring phase: 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)

Disposition

Current setting: ed — Recognize the airway emergency from across the room; KEEP THE CHILD CALM; defer the throat exam; activate the most experienced airway operator + ENT + anesthesia; move to a controlled environment (OR) for definitive airway BEFORE obstruction (AAP Red Book 2024-2025; pediatric airway-emergency literature)

Disposition criteria:
- All suspected epiglottitis → controlled OR airway then PICU; never discharge from ED with stridor + drooling + toxic appearance (pediatric airway-emergency literature)

Escalation triggers (move to higher acuity):
- Any impending-obstruction red flag → immediate OR for controlled airway (pediatric airway-emergency literature)
- Sudden complete obstruction → bag-mask ventilation bridge → emergent surgical airway by the most experienced operator (pediatric airway-emergency literature)
- Pre-arrest (agitation → fatigue / quiet child / bradycardia / falling SpO2) → emergent airway NOW (pediatric airway-emergency literature)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Tripod posture + drooling + stridor at rest + muffled "hot-potato" voice + toxic appearance + "sniffing" position — impending complete airway obstruction (AAP Red Book 2024-2025; pediatric airway-emergency literature)
- [LIFE_THREATENING] Agitation → fatigue / quiet child / falling SpO2 / bradycardia — pre-arrest, obstruction imminent or occurring (pediatric airway-emergency literature)
- [LIFE_THREATENING] Hot-liquid scald / steam / smoke inhalation / caustic ingestion / vapor inhalation with progressive supraglottic edema — non-infectious supraglottitis (pediatric airway-emergency literature)

Citations

- AAP Red Book 2024-2025 (H. influenzae type b + S. pyogenes + S. aureus chapters; post-Hib epidemiology; rifampin chemoprophylaxis) + IDSA invasive deep-neck / supraglottic empiric-therapy principles + recent (post-Hib-vaccine-era) pediatric-otolaryngology airway-emergency literature; vancomycin AUC per Rybak IDSA 2020 [PMID:32191793](https://pubmed.ncbi.nlm.nih.gov/32191793/)
- Cited evidence (PMID 9498385) [PMID:9498385](https://pubmed.ncbi.nlm.nih.gov/9498385/)
- Cited evidence (PMID 20308772) [PMID:20308772](https://pubmed.ncbi.nlm.nih.gov/20308772/)
- Cited evidence (PMID 26020374) [PMID:26020374](https://pubmed.ncbi.nlm.nih.gov/26020374/)
- Cited evidence (PMID 31058071) [PMID:31058071](https://pubmed.ncbi.nlm.nih.gov/31058071/)

Last reconciled with current guidelines: 2026-05-15.
References
  • AAP Red Book 2024-2025 (H. influenzae type b + S. pyogenes + S. aureus chapters; post-Hib epidemiology; rifampin chemoprophylaxis) + IDSA invasive deep-neck / supraglottic empiric-therapy principles + recent (post-Hib-vaccine-era) pediatric-otolaryngology airway-emergency literature; vancomycin AUC per Rybak IDSA 2020 — PMID:32191793
  • Cited evidence (PMID 9498385) — PMID:9498385
  • Cited evidence (PMID 20308772) — PMID:20308772
  • Cited evidence (PMID 26020374) — PMID:26020374
  • Cited evidence (PMID 31058071) — PMID:31058071