A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 5-year-old boy is brought to the emergency department by his grandmother because of difficulty breathing. Over the past two hours, the grandmother has noticed his voice getting progressively hoarser and occasionally muffled, with persistent drooling. He has not had a cough. The child recently immigrated from Africa, and the grandmother is unsure if his immunizations are up-to-date. He appears uncomfortable and is sitting up and leaning forward with his chin hyperextended. His temperature is 39.5°C (103.1°F), pulse is 110/min, and blood pressure is 90/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Pulmonary examination shows inspiratory stridor and scattered rhonchi throughout both lung fields, along with poor air movement. Which of the following is the most appropriate next step in management?
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A
Nebulized albuterolIncorrect. Nebulized albuterol treats bronchospasm in asthma; this child has upper airway obstruction from a swollen epiglottis, where albuterol will not help.
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B
PharyngoscopyIncorrect. Pharyngoscopy in suspected epiglottitis can precipitate complete laryngospasm and airway loss in an awake child and is contraindicated outside the OR/controlled setting.
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C
Intravenous administration of antibioticsIncorrect. IV antibiotics (ceftriaxone) are essential treatment but only after the airway is secured; an unprotected airway is the immediate threat to life.
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D
Nasotracheal intubationCorrect. Definitive airway control with nasotracheal intubation in a controlled OR setting, with surgical airway backup, takes priority over all other interventions in suspected epiglottitis.
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E
Racemic epinephrine via nebulizerIncorrect. Racemic epinephrine is appropriate for moderate croup with stridor, but in suspected epiglottitis it delays definitive airway management and risks airway loss in an unstable child.
↑ Tap an answer to reveal the reasoning
Answer: D. A young, possibly unvaccinated child with rapidly progressive fever, drooling, muffled "hot-potato" voice, inspiratory stridor, and the tripod/sniffing position (sitting up, leaning forward, chin extended) has acute epiglottitis. Before widespread Hib vaccination this was caused by Haemophilus influenzae type b; in an under-immunized child from outside the U.S., Hib remains the leading suspect.
The airway is the priority — these children can lose it within minutes, and any agitation (including direct visualization of the throat with a tongue depressor or pharyngoscopy) can precipitate complete obstruction. The most appropriate next step is securing the airway in a controlled setting, typically the OR, by an experienced team — nasotracheal (or orotracheal) intubation with surgical airway backup ready. IV antibiotics (ceftriaxone) and steroids follow, but only AFTER the airway is secured.
The rule for any toxic child in a tripod position with drooling: do not examine the throat, do not start IVs in the ED, do not lay them flat — go to the OR for definitive airway control.
**Why each option:**
**A.** Nebulized albuterol treats bronchospasm in asthma; this child has upper airway obstruction from a swollen epiglottis, where albuterol will not help.
**B.** Pharyngoscopy in suspected epiglottitis can precipitate complete laryngospasm and airway loss in an awake child and is contraindicated outside the OR/controlled setting.
**C.** IV antibiotics (ceftriaxone) are essential treatment but only after the airway is secured; an unprotected airway is the immediate threat to life.
**D.** Correct. Definitive airway control with nasotracheal intubation in a controlled OR setting, with surgical airway backup, takes priority over all other interventions in suspected epiglottitis.