Approximately 20% of asymptomatic

school-aged children are chronic carriers of GABHS.

In patients with infectious mononucleosis, a complete

blood count will typically show lymphocytosis with a

preponderance of atypical lymphocytes (> 10%).

Heterophile antibody (Monospot) or EBV titers are used

to confirm the presence of infectious mononucleosis.

Monospot is very insensitive in children younger than 4

years of age. Liver enzymes may also be elevated.

..... Imaging

A soft tissue lateral neck radiograph may be helpful to visualize an aspirated foreign body or narrowing of the tracheal

air column (masses). The "thumb print'' sign is seen with

epiglottitis (Figure 53-2A). Widening of the retropharyngeal

space is seen with a retropharyngeal abscess (Figure 53-2B).

The normal retropharyngeal soft tissue space is defined as

<7 mm at C2, < 14 mm at C6 in children, and < 22 mm at

C6 in adults. Computed tomography (CT) scan of the neck

may be required for the definitive diagnosis of peritonsillar

or retropharyngeal abscess.

MEDICAL DECISION MAKING

Patients with signs and symptoms of toxicity or severe

respiratory distress need to be emergently evaluated for the

possibility of epiglottitis, retropharyngeal abscess, or

peritonsillar abscess. The history and physical examination

will help to differentiate between these conditions.

Using either the Strep score (Table 53-1) or modified

Centor criteria ( Table 53-2) can help in the decision to test

and treat patients with pharyngitis (Figure 53-3). Consider

an alternative diagnosis of viral pharyngitis or foreign

body if clinically indicated.

Table 53-1. Strep Score (each factor is worth 1 point).

• Fever > 38.3°( (1 01 °F)

• Age 5-15 years

• Season (November-May)

• Evidence of pharyngitis on exam (erythema, edema, exudates)

• Tender, enlarged > 1 em anterior cervical lymph nodes

• Absence of upper respiratory infection signs/symptoms

Scoring:

Points PPV Diagnosis/Treatment

0-1 2% Supportive care

2-4 20-40% Rapid test and treat accordingly

5-6 60-75% Consider empiric treatment

CHAPTER 53

Table 53-2. Mod ified Centor Criteria.

Criteria

Fever >38°( (101 .4°F)

Absence of cough

Tender, enlarged anterior cervical lymph

nodes

Tonsillar exudates

Age

3-14 years

1 5-44 years

45 years or older

TREATMENT

Points

0-1

2-3

4-6

Points

1

0

-1

Diagnosis/Treatment

Supportive care

Rapid test/culture and

treat accordingly

Consider empiric

treatment ± culture

Epiglottitis. Place the patient in a position of comfort

(parent's lap), avoid agitating the patient, and administer

supplemental 02" Obtain ear, nose, and throat (ENT)

consultation with the goal to secure the airway in the

operating room.

Retropharyngeal abscess. Start intravenous (N) antibiotics (ampicillin-sulbactam 50 mg/kg or clindamycin

13 mg/kg). Obtain ENT consultation for surgical drainage

if the CT reveals an abscess.

Peritonsillar abscess. Start N antibiotics (ampicillinsulbactam or clindamycin). Needle aspiration and/or incision and drainage in ED can be done in older children.

Surgical drainage of the abscess in the operating room will

be necessary for children requiring significant sedation.

Pharyngitis. Advise symptomatic treatment with warm

salt water gargles (not for young children who will swallow

the salt water) and acetaminophen (15 mg/kg every

4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours).

Antibiotics are prescribed in patients with suspected or

confirmed GABHS. Oral choices of antibiotics include

penicillin (25-50 mg/kg day PO TID or QID for 10 days),

amoxicillin (50 mg/kg!day PO BID-TID for 10 days), or a

first-generation cephalosporin. Benzathine penicillin ( <27 kg:

600,000 units; >27 kg: 1 .2 million units) can be given intramuscularly to ensure compliance. Patients with penicillin

or cephalosporin allergies can be given either erythromycin ethyl succinate ( 40 mg/kg/ day PO BID or TID for

10 days), azithromycin (children: 12 mg/kg/day PO, maximum dose 500 mg/day PO for 5 days; adolescents and

adults 500 mg tablet on day 1 followed by 250 mg tablet on

days 2-5), or clindamycin (20 mg/kg!day PO TID for 10

days, maximum 1.8 g/day).

DISPOSITION

..... Admission

Admit patients with epiglottitis and retropharyngeal

abscess with potential airway compromise to an intensive

care unit. Young patients with peritonsillar abscess who

cannot be drained in the ED or are unable to tolerate

liquids also require admission. When Kawasaki disease is

suspected or pharyngitis causes severe dysphagia preventing adequate oral intake, admission may be necessary.

..... Discharge

Patients with a peritonsillar abscess drained either by

needle aspiration or incision and drainage who are

tolerating oral fluid adequately can be discharged from the

ED. The first dose of antibiotics should be given N.

Uncomplicated pharyngitis in patients tolerating oral fluids can also be discharged from the ED.

SUGGESTED READING

Caglar D, Kwun R. The mouth and throat. In Tintinalli JE,

Stapczynski JS, Cline DM, Ma OJ, Cydulka R.K, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 20 11, pp. 774-782.

Fleischer GR. Sore throat. In: Fleisher GR, Ludwig S. Textbook of

Pediatric Emergency Medicine. 6th ed. Philadelphia, PA:

Lippincott Williams & Wilkins, 20 1 0, pp. 579-583.

Gunn JD Ill. Stridor and drooling. In Tintinalli JE, Stapczynski

JS, Cline DM, Ma OJ, Cydulka R.K, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 201 1, pp. 788-796.

PHARYNGITIS

Throat pain

Assess for signs of toxicity

or respiratory distress

2. Supportive care

.&. Figure 53-3. Pharyngitis diag nostic algorithm.

The Poisoned Patient

Sean M. Bryant, MD

Key Points

• A thorough history of present ill ness including information gathered from available friends, family, and

emergency medical service personnel can be invaluable

in the management of poisoned patients.

• Perform a comprehensive physical exam including a fu ll

set of vital signs t o h e l p classify the patient's clinical

presentation into a particu lar toxidrome.

INTRODUCTION

More than 2 million toxic exposures and poisonings are

reported to U.S. regional poison centers annually.

Consequently, all emergency physicians should possess a

basic fundamental comprehension of emergency

toxicology and a sound clinical approach for managing

the poisoned patient. Depending on the absolute dose

and/or duration of exposure, all substances have the

potential for harm. Factors including the absorption,

distribution, and elimination rate of the inciting agent

help determine its overall toxicity. In poisoned patients,