What is the recommended emergency airway management and antibiotic regimen for a preschool‑aged child (2–6 years) presenting with rapid onset fever, sore throat, dysphagia, drooling, muffled voice and tripod posture suggestive of epiglottitis?

Emergency Management of Epiglottitis in Children

Immediate Airway Priorities

Do not examine the throat, obtain lateral neck X-rays, or delay airway management—immediately summon an airway specialist (anesthesiologist, otolaryngologist, or intensivist) and transport the child directly to the operating room for controlled intubation under inhalation anesthesia. 1, 2

Critical First Actions

• Minimize agitation by allowing the child to remain in the position of comfort (typically sitting upright in tripod position) with a parent present, as any distress can precipitate complete airway obstruction 1, 3
• Apply high-flow oxygen gently to the face without forcing a mask, maintaining SpO₂ ≥94% 4
• Never perform direct visualization of the pharynx with a tongue depressor or attempt to lay the child supine, as this can trigger laryngospasm and complete obstruction 1, 2
• Avoid any invasive procedures (IV placement, blood draws, radiographs) until the airway is secured, as these provoke crying and worsen obstruction 2, 5

Airway Management Algorithm

Step 1: Operating Room Setup (Before Touching the Child)

• Assemble a multidisciplinary team including the most experienced anesthesiologist, otolaryngologist, and nursing staff available 4, 1
• Prepare multiple airway devices: direct laryngoscope with multiple blade sizes, videolaryngoscope, supraglottic airways (second-generation preferred), fiberoptic bronchoscope, and emergency tracheostomy tray at bedside 6, 4, 7
• Have cuffed endotracheal tubes ready in multiple sizes (0.5 mm smaller than age-predicted due to supraglottic edema), maintaining cuff pressure ≤20 cm H₂O once placed 7

Step 2: Induction and Intubation Technique

• Perform inhalation induction with sevoflurane or halothane while the child remains sitting or in the parent's arms, allowing spontaneous ventilation throughout 6, 3
• Position the child in "sniffing" position (neutral head with shoulder roll for children under 2 years) only after adequate depth of anesthesia is achieved 7
• Limit direct laryngoscopy attempts to maximum 2 by the most senior practitioner, using a stylet or bougie if difficult glottic visualization 6, 7
• If direct laryngoscopy fails after 2 attempts, immediately insert a supraglottic airway device (maximum 3 attempts) to maintain oxygenation, then perform fiberoptic-guided intubation through the supraglottic airway 6, 7
• If SpO₂ drops below 80% despite supraglottic airway or heart rate decreases, the ENT surgeon must immediately perform emergency tracheostomy or rigid bronchoscopy with jet ventilation 7

Step 3: Post-Intubation Stabilization

• Secure the endotracheal tube meticulously with multiple methods (tape and ties), as accidental extubation in a child with epiglottitis can be catastrophic 7, 2
• Obtain blood cultures after the airway is secured (not before), as post-intubation cultures have significantly higher yield for Haemophilus influenzae 5
• Admit to pediatric intensive care unit for continuous monitoring with 1:1 nursing 1

Antibiotic Regimen

Initiate intravenous ceftriaxone 50 mg/kg/day (maximum 2 g/day) immediately after securing the airway and obtaining blood cultures. 6, 1

Antibiotic Selection Rationale

• Ceftriaxone provides optimal coverage for Haemophilus influenzae type B (the predominant pathogen in unvaccinated or partially vaccinated children) and other potential pathogens including Streptococcus pneumoniae and Staphylococcus aureus 6, 1
• For children with documented β-lactam allergy (immediate Type I hypersensitivity), use a respiratory fluoroquinolone (levofloxacin 10 mg/kg/dose every 12-24 hours based on age) after infectious disease consultation 6
• Continue antibiotics for 7-10 days total, transitioning to oral therapy (amoxicillin-clavulanate 90 mg/6.4 mg per kg per day) once extubated and tolerating oral intake 6

Extubation Criteria and Technique

• Plan extubation after 24-48 hours of antibiotics when the child is afebrile, has decreasing inflammatory markers, and direct laryngoscopy shows significant reduction in supraglottic edema 6, 2
• Administer intravenous dexamethasone 0.6 mg/kg (maximum 10 mg) 4-6 hours before planned extubation to reduce laryngeal edema 6
• Perform extubation in the operating room with the ENT surgeon present and emergency tracheostomy equipment immediately available, as reintubation may be impossible due to residual edema 6, 7
• Use epinephrine nebulization (0.5 mL/kg of 1:1000 solution, maximum 5 mL) immediately post-extubation if stridor develops, recognizing its effect lasts only 1-2 hours 8

Critical Pitfalls to Avoid

• Never obtain lateral neck radiographs in a child with suspected epiglottitis—the classic "thumb sign" does not change management and delays definitive airway control 1, 5
• Never attempt bag-mask ventilation before adequate depth of anesthesia, as positive pressure can convert partial obstruction to complete obstruction 3, 9
• Never use neuromuscular blocking agents until you have confirmed the ability to ventilate, as paralysis eliminates the child's only mechanism for maintaining airway patency 7, 3
• Never discharge a child with suspected epiglottitis for outpatient observation—all cases require ICU admission regardless of initial appearance 1