1, 2, 3 pokes to empowerment! - henryfordem.compta, rpa, pharyngitis & tracheitis david ahee,...
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PTA, RPA, PHARYNGITIS & TRACHEITIS
DAVID AHEE, M.D.
HENRY FORD HOSIPTAL
DEPARTMENT OF EMERGENCY MEDICINE
1, 2, 3 Pokes To Empowerment!
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Goals & Objectives
Clinical presentation, diagnosis & treatment of various throat pathology
Give you all the confidence of “ENT Bob” (in sticking an 18ga needle within inches of one’s carotid artery)
Prove that RPA is an actual entity
Highlight potential morbidity / mortality
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A Primer…
Deep tissue infections of the neck
Easy communication to / interference with high risk areas…mastoid bone, mediastinum, trachea…
Not especially common…essential to diagnose & treat correctly
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Case #1
One afternoon in Cat 3…
26yo Female with complaint of ear infection / sore throat…
Otherwise healthy, ear pain and sore throat worsening x 4 days, worse on the left, associated with fever of 38.2, dysphagia and change in voice. No ear drainage, no decreased auditory acuity. Using Motrin with minimal relief…
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Anatomy
Uvula
Palatoglossal Fold
Palatopharyngeal Fold
Retropharyngeal Space
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Sagittal View
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In real life…
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Physical Exam
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Quinsy Clinical Features
Unilateral Sore Throat
Fever/Chills
Dysphagia / Odynophagia
Change in Voice Quality “Hot Potato”
Trismus (pain / muscle spasm with opening mouth)
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PTA PE
Erythema / edema / exudates of affected tonsil
Bulging (swelling) of affected tonsil
Contralateral deviation of uvula
Palpate for area of fluctuance (SHOULD NOT PULSATE)
Tender Cervical Adenopathy
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PTA Organisms
Usually Polymicrobial
Staphylcoccus aureua, Streptococci (Group A, Beta-Hemolytic), Hemophilus Influenzae, Anaerobes
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PTA Imaging
CT Neck with IV Contrast Areas of fluid collection
Fat Stranding
Ultrasound Intraoral verse Transcutaneous
Endocavitary “Vaginal” Probe
Allows visual of carotid artery
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An Amazing Machine…
June 2012 Academic Emergency Medicine
Constantino et al, at Temple University
Intraoral US verse Landmark-based Needle Aspiration
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Treatment
Evaluate the airway! Airway distortion + trismus = Potential Disaster
If compromised preferred by awake fiberoptic
Antibiotics Clindamycin
Penicillin + Flagyl
Ampicillin / Sulbactam or Ampicillin / Clavulanate
Corticosteroids
Needle Aspiration Diagnostic & Therapeutic
No need for ENT consult!
Incision & Drainage Okay, go ahead and call ENT
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Needle Aspiration
1. Equipment
2. Position
3. Anesthesia
4. Three Pokes
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Needle Aspiration
1. Equipment: Cetacaine Spray
1% lidocaine with Epi
3cc Syringe
10cc Syringe
25ga Needle
18ga Needle
Tongue Blades (2-3)
Kidney Basin
Normal Saline with Drinking Cup
Suction (Yaunker)
Light Source (Headlamp)
+/- Sterile Tube or Culture Swabs
2. Position Sitting Upright
+/- Head Support
3. Anesthesia Parental – Fentanyl 25-50
mcg IV x1
Topical – Viscous Lidocaine, CetacaineSpray, Tetracaine, Local Infiltration
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1. Equipment
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Now a close up…
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A few more tricks…
Try a macintosh blade as tongue depressor & light!
Use a spinal needle for better visualization!
Photo courtesy of Dr. Hagop Afarian (Fresno)
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Needle Aspiration
4. Three PokesSuperior Pole Middle Pole Inferior Pole
Sagittal Plane – never angle needle/syringe laterally
Keep needle medial to second molar
Internal carotid artery 2.5 cm posterolateral to tonsil
Usually 2-6 mL of purulent fluid
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Complications
Bleeding
Aspiration of purulent material / blood Suction
Cyanosis + DIB = Methemoglobinemia Methylene Blue
Carotid Artery Puncture Use of Ultrasound
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SUCCESS!
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Case #2
One sunny afternoon at Fairlane…
3yo male with c/o fever…
Mom gives hx of fever x 3 days, Tmax = 102.1, decreased oral intake, decreased activity, no sick contacts, immunizations UTD…
5 days ago patient fell while eating a popsicle…
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Anatomy
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How?
Direct Extension (Anteriorly or Posteriorly)
Local Trauma (think iatrogenic)
Suppuration of Lymph Nodes
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But does it really exist?
In US in 2003, 1321 cases of RPA
In Detroit…
Retropharyngeal abscess in children: the rising incidence of methicillin-resistant Staphylococcus aureus.Abdel-Haq N; Quezada M; Asmar BIDivision of Infectious Diseases, Children's Hospital of Michigan, and Carman and Ann Adams Department of Pediatrics, Wayne State University, Detroit, MI, USA
114 children (61 males) with RPA identified from 2004-2010, 2.8-fold increase in incidence (per 10,000 admissions) over the previous 11-year period (1993-2003)
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Clinical Features
By History:
Fever
Sore Throat
Dysphagia
Trismus
Neck Pain / Stiffness
Muffled Voice
By Physical Exam:
Bulge in Posterior Pharynx
Stridor / Drooling = Airway Compromise
Nuchal Rigidity
Agitation / Lethargy
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What’s Next? A B C…X
Lateral View Soft Tissue Neck
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Treatment
1-800-CHM-KIDS
Admission and IV antibiotics Clindamycin + Ceftriaxone
Pen G + Flagyl
Zosyn
Pediatric ENT Consultation
+/- OR I&D
Prophylactic Endotracheal Intubation
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Complications
Airway Obstruction
Aspiration
Mediastinitis
Epidural Abscess
Internal Jugular Vein Thrombosis
Erosion to Carotid Sheath
Necrotizing Fasciitis
Sepsis
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Case #3 – Treat? Test? Do Nothing?
Back in Cat 4 on a cool April morning…
13yo male who c/o sore throat, decreased PO intake due to the pain, tactile fever and swollen glands. Denies runny nose, cough and nasal congestion. You note erythema, no exudates.
19yo female who c/o sore throat, afebrile, states third similar episode over last 5 months, you note several Cat 3 visits “to be checked out,” with negative cultures.
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Case #3 – Treat? Test? Do Nothing?
16yo male with c/o sore throat and malaise, you note significant tonsillar exudates and posterior cervical and occipital adenopathy.
9yo female with c/o sore throat associated with a watery eye, runny nose, cough and nasal congestion. Younger sibling with similar symptoms.
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Oh The Possibilities…
Viral pharyngitis: rhinovirus, adenovirus, influenza, CMV, EBV, HIV, HSV, coxsackieviruses
Fungal pharyngitis: Candida sp.
Bacterial pharyngitis: GABHS, GC, chlamydia trachomatis, mycoplasma pneumoniae, diptheria, TB, chlamydia pneumoniae, anaerobes
Allergic Pharyngitis
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Diagnostic Strategies
GABHS Centor Criteria RSA Screen
EBV Monospot
STIs – GC/Chlamydia Cultures
Assessing each clinical situation (patient age, risk factors, toxic/non-toxic)
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Picture Quiz!
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Picture Quiz!
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Diptheria
Corynebacteriumdiphtheriae produce systemic toxin
Grey or white exudates that form pseudomembrane
Well demarcated
May extend into larynx and tracheobronchial tree
Bull Neck Appearence
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Diptheria
Throat Culture & Gram Stain
Diptheria Antitoxin
Penicillin / Erythromycin
Td immunization every 10 years
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Case #4
At your last Fairlane shift of the month…
7yo female with hx of recent URI presents with DIB…
39.4 C, 102/72, 144, 38, 94%RA
Ill appearing, accessory muscle use, inspiratory and expiratory stridor…
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Bacterial Laryngotracheobronchitis
AKA: Bacterial Tracheitis, Bacterial Croup, Pseudomembranous Croup
Hybrid of croup and epiglottitis
Precedent viral URI, damages tracheal mucosa
Bacterial superinfection with copious secretions
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Bacterial Laryngotracheobronchitis
3 – 5 years of age
Classically S. aureus; also…
H. Influenza, Moraxella catarrhalis, Peptostreptococcus, Prevotella and Fusobacterium
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Diagnosis
Lateral Soft Tissue Neck Xray
Irregular “shaggy” tracheal air column
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Treatment
Airway majority require intubation Suctioning Direct Laryngoscopy aids in diagnosis
Smaller ET Size
Bronchoscopy
Antibiotics 3rd Gen Cephalosporin + Penicillinase-resistant Penicillin
Clindamycin
Vancomycin
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Recap
High Clinical Suspicion Less common but serious complications
PTA ≠ ENT
PTA = US
Consider the zebras next time you see c/o “Sore Throat”
ABC
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Questions?
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References
Marx, Rosen's Emergency Medicine, 7th Edition
Roberts, Clinical Procedures in Emergency Medicine, 5th Edition
LeBlond RF, DeGowin RL, Brown DD. Chapter 7. The Head and Neck. In: LeBlond RF, DeGowin RL, Brown DD, eds. DeGowin's Diagnostic Examination. 9th ed. New York: McGraw-Hill; 2009. http://www.accessmedicine.com/content.aspx?aID=3660155. Accessed February 20, 2013.
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Medscape Reference
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The Pocket Guide to Needle Aspiration of Quinsy (PTA) – 4 Easy Steps!
1. Equipment Cetacaine Spray 1% lidocaine with Epi 3cc Syringe 10cc Syringe 25ga Needle 18ga Needle (? Spinal Needle) Tongue Blades (2-3) Kidney Basin Normal Saline with Drinking Cup Suction (Yaunker) Light Source
Headlamp Macintosh Laryngoscope
+/- Sterile Tube or Culture Swabs
2. Position Seated, facing forward +/- Head Support
3. Anesthesia Parental – Fentanyl 25-50 mcg IV x1 Topical – Viscous Lidocaine,
Cetacaine Spray, Tetracaine, Local Infiltration
4. Three PokesSuperior Pole Middle Pole
Inferior Pole (1cm spacing)
Sagittal Plane – never angle needle/syringe laterally
Keep needle medial to second molar
Internal carotid artery 2.5 cm posterolateral to tonsil
2 – 6 mL of Pus
Tips & Tricks Cut needle cap to expose 1cm of
needle, acts as a guard Use the US to evaluate PTA verse
Cellulitis!