HEENT Emergencies and Eye Trauma PDF

HEENT EMERGENCIES Rachel Elbing PA-C, MPH Augsburg PA Program Spring 2025 Objectives 1. Summarize the etiology, pathophysiology, clinical features, how diagnosis is established, potential complications and treatment for the conditions listed below: Epistaxis Nasal trauma &...

HEENT EMERGENCIES Rachel Elbing PA-C, MPH Augsburg PA Program Spring 2025 Objectives 1. Summarize the etiology, pathophysiology, clinical features, how diagnosis is established, potential complications and treatment for the conditions listed below: Epistaxis Nasal trauma & nasal bone fracture Peritonsillar abscess Angioedema Denies caries and abscesses Ludwig angina Deep neck abscess Epiglottitis Foreign bodies (eyes, nasal, ear and upper airway) Laryngotracheobronchitis (croup) Facial trauma & facial bone fractures Blowout fracture Globe rupture 2. Establish guidelines for the indications and management of a tracheostomy and cricothyrotomy. 3. Assess a patient with HEENT trauma, diagnose and manage appropriately in an acute care setting. Epistaxis - Overview Common and usually uncomplicated Complicated nosebleeds can be really complicated! Most are ANTERIOR - KIESSELBACH’S PLEXUS Pressure, topical decongestants, cautery, packing Posterior, bilateral, or large-volume = complicated! Ask about meds, specifically _________????  Epistaxis - History Duration - When did it start? How long has it been bleeding? Frequency - Has it been on/off for several days? Quantity Any trauma? Medications Medical history (specifically bleeding disorders)  Epistaxis - Etiology Nasal trauma ○ Nose picking, foreign bodies, forceful nose blowing Rhinitis Mucosal drying - low humidity or supplemental O2 Figures: HHT associated nasal telangiectasias. Note the dilated nest of Deviated septum capillaries surround by normal pink Telangiectasias - Hereditary Hemorrhagic Telangiectasia mucosa of the nasal septum Inhaled drug use Alcohol abuse Atherosclerosis Poorly controlled HTN **Anticoagulation/antiplatelet meds may be associated with higher incidence, more frequent recurrence, and more difficulty controlling but does not CAUSE epistaxis!  Epistaxis - Pathophysiology Anterior Bleeds ○ Most common! ○ Easier to control (pressure!) ○ Kiesselbach’s Plexus ~90% of bleeds Posterior Bleeds ○ Commonly associated with atherosclerosis and HTN ○ Sometimes require admission ○ Branches of sphenopalatine artery  Epistaxis - Exam Preparation is key! ○ Head lamp or good light source ○ Suction ○ Tongue blade ○ PPE (eye protection, gown) ○ Talk with the patient - this is stressful! Often initial exam is limited by hemorrhage Once hemostasis is achieve, attempt to localize bleeding point to determine treatment  Epistaxis - Management Is patient critically ill? → IV, O2, monitor Airway. Airway. Airway. ○ Have patient sit upright ○ Suction to prevent blood flowing down posterior pharynx ○ Intubate if patient is unable protect airway Breathing ○ If patient has respiratory compromise it is likely secondary to airway issue Circulation ○ Resuscitate with IV fluids ○ Transfuse pRBCs ○ Reverse any coagulopathy Epistaxis - Management Stepwise approach Sit upright and leaning forward Have patient blow nose - remove clots Apply local pressure for 15 min Reassess If still bleeding → topical vasoconstrictors Apply topical anesthetics Apply pressure again Reassess Silver nitrate stick if bleeding localized Packing if bleeding site not identified or attempts for direct control unsuccessful Epistaxis - Medication Topical Decongestant (vasoconstriction) ○ Oxymetazoline (Afrin) ○ Phenylephrine nasal spray Silver Nitrate ○ Coagulates cellular protein and forms eschar Topical Anesthetic ○ Lidocaine or tetracaine Other hemostatic agents ○ Topical 4% Cocaine - anesthetic and vasoconstrictor ○ TXA (Tranexamic Acid) soaked gauze  Epistaxis - Packing options Rhino rocket Merocel foam Thrombogenic foams (Surgicel, Gelfoam) Rapid Rhino Epistaxis Management Video  Epistaxis - TXA Application https://www.youtube.com/watch?v=ekGsM9CZSpY  Anterior Packing Epistaxis - Posterior Bleeding Usually require posterior packing Often ENT consult Balloon Catheters Hospitalization can be required Posterior Packing If conservative tx failure: https://www.emrap.org/episode/epistaxis1/epistaxis ○ Surgical: ligation of sphenopalatine or anterior ethmoid artery ○ IR: Angiographic embolization  Epistaxis - Follow up Packing should removed in 24-48 hours ○ ENT vs primary care ○ Wet merocel packing before removal for patient comfort Advised not to blow nose for 7-10 days Antiseptic nasal cream/ointment for moisture Antibiotic coverage - antistaphylococcal coverage ○ Controversial - consider in higher risk pts ○ Antistaphylococcal antibiotics (cephalexin, clindamycin) to reduce risk of TSS Peritonsillar Cellulitis & Abscess - Overview Peritonsillar Cellulitis ○ Inflammatory reaction between palatine tonsil and pharyngeal muscles ○ No pus collection ○ Resolves usually with meds Peritonsillar Abscess “Quinsy” ○ Pus collection in the same space ○ Needs drainage! Usually preceded by pharyngitis/tonsillitis Muffed, Hot Potato Voice Polymicrobial - Strep, staph, anaerobes  PTA - Presentation Presentation Exam Severe sore throat Trismus ○ Often worse on ONE side Medial deviation of soft palate and Fever peritonsillar fold Odynophagia Muffled “Hot Potato” voice Trismus Swollen, fluctuant tonsil Changing voice Uvular deviation to opposite side  PTA - Evaluation Clinical evaluation ○ Clinical impressure 78% sensitive, 50% specific CT scan - soft tissue neck ○ 100% sensitive; 75% specific Ultrasound  PTA - Management Needle aspiration and/or Incision & Drainage! Needle aspiration often done by ER provider ○ Topical anesthesia ○ Can be done with US ○ Complications: hemorrhage, aspiration of blood/pus into airway, ?carotid artery puncture Methods to make sure needle does not go too deep I&D often ENT ○ More painful, more bleeding, higher risk of aspiration Tonsillectomy if treatment failure or recurrence (10% of patients) PTA - Landmarks and supplies I&D Kit 20g Spinal Needle ○ Cut distal needle sheath so last 1cm of needle is exposed (avoid carotid) Anesthetic spray Laryngoscope (or lower part of speculum as above) - can have patient hold Suction Ultrasound if available PTA - Management Video  PTA - Management (in addition to drainage) Antibiotics ○ Typically IV dose following by PO regimen ○ Augmentin or Clindamycin Steroids Analgesia - considering opioids, liquid forms available IV fluids ○ Patients can be dehydrated Consults - ENT Disposition ○ Can discharge those hemodynamically stable, tolerating PO and no airway concerns ○ Admit if difficulty tolerating PO, systemic infection, airway concerns  Angioedema Review Edema into deeper layers of skin Causes: IgE: Similar reaction to ________ but with deeper involvement into the dermis ○ Generally face, neck, distal extremities ○ Tongue, lips, face → AIRWAY What medication is associated with angioedema? ______________ Hereditary angioedema ○ Autosomal dominant disorder → deficiency of C1 esterase inhibitor  Angioedema Management AIRWAY! IgE induced - how would you treat? ACEI-induced angioedema ○ Epi, antihistamine, steroids not beneficial here (no IgE) ○ Icatibant (bradykinin-2 antagonist) can be helpful Hereditary angioedema ○ C1 esterase inhibitor ○ Icatibant Dental Caries and Abscesses - Dental Anatomy  Dental Caries and Abscesses - Overview Very common Most of the time overall benign - dental caries and periapical abscess cm. Treatment: ○ ________________________ ○ Refer to dentistry  Dental Caries and Abscesses - Etiology, Sx and w/u Enamel/dentin demineralizes secondary to bacteria Bacteria adhere to teeth & form dental plaque ○ Metabolized sugars and biproducts lead to erosion ○ Brushing removes the plaque ○ Fluoride decreases susceptibility Sxs: cavity in enamel, pain, pulpitis, loss of tooth Imaging: XRs show defect in enamel but often clinical diagnosed when seen at pcp, UC, or ER Treatment: Usually PO antibiotics (____________, ______________) ○ I&D if possible. Dental abscess drainage  Dental Caries and Abscesses - Complications DO NOT MISS PHYSICAL EXAM FINDINGS: Stridor Drooling Trismus Ludwig Angina - Overview Bilateral infection of submandibular, sublingual, and submental spaces the begin in the floor of the mouth Often polymicrobial, strep viridans most common Most common cx ____________________! “Woody” cellulitis Progresses rapidly! Risk factors: Diabetes, Lupus, Alcoholism, Immunocompromised Airway compromise can be a complication IV antibiotics and close observation; maybe surgery if fluid collection Ludwig Angina - Presentation Fever, chills, malaise - septic appearing often Mouth pain, stiff neck, drooling, dysphagia Changing, “muffled” voice More difficulty breathing if airway becomes affected Ludwig Angina - Exam Can be septic appearing Tender, symmetric, “woody/brawny” induration Edema and erythema under chin and flour of mouth Mouth often held open (swelling below) Floor of oral cavity elevated, https://www.emrap.org/episode/ludwigsangina/ erythematous, and tender to palpation ludwigsangina Ludwig Angina - Diagnosis Clinical diagnosis supported with imaging Imaging - _____________________________ ○ Soft tissue thickening ○ Increased attenuation of subcutaneous fat ○ Loss of fat planes in submandibular space ○ Gas bubbles w/i soft tissues ○ Focal fluid collections ○ Muscle edema Can do MRI if unable to do CT What labs would you get? Ludwig Angina - Management IV, O2, Monitor Airway management! IV antibiotics - oral flora aerobes and anaerobes; consider MRSA ○ Augmentin ○ Ceftriaxone PLUS Metronidazole ○ MRSA? → Vanco or Linezolid ENT consultation Occasional surgical management - if fluid collection present Deep Neck Infection Locations ○ Parapharyngeal - Overview ○ Retropharyngeal ○ Prevertebral Typically from infection of teeth, tonsils, middle ear, sinuses ○ Infection spreads along cervical plane Polymicrobial: Strep, Staph, H.flu, gram neg, anaerobes Systemic toxicity CT neck imaging of choice Stability airway!, IV antibiotics, Drainage  Deep Neck Infection - Presentation Systemic symptoms (Fevers, chills) Sore throat Neck pain/swelling, torticollis, trismus Stridor, dyspnea, airway obstruction Drooling, muffled “hot potato” voice Deep Neck Infection - Evaluation and Management IV, O2, Monitor Labs, cultures Pain meds, IV fluids CT scan - With or without contrast?? Xrays can be used but limited value - will need CT scan Broad Spectrum IV antibiotics and admission Aspiration or open drainage of abscess  Retropharyngeal abscesses Parapharyngeal abscess  A special case - Lemierre syndrome Treat with antibiotics. Anticoagulation is controversial  AKA “Supraglottitis” Epiglottitis - Overview Affects children and adults ○ Children: Unimmunized - _____________ ○ Adults: DM, HTN, immunocompromised Can progress quickly Anxiety, “tripod position”, muffled voice, stridor Dx: Visualized on laryngoscope Xray: “____________________” Mgt: Airway most important, then admission, IV antibiotics  Epiglottis - Etiology Children: H.flu type B (Hib) was most common until Hib vaccine ○ 5/100,000 → 0.6/100,000 Strep and Staph Adults: Strep pneumoniae, Group A Strep, Staph, Hib Viral Not infectious: Thermal, caustic ingestion, FB ingestion  Epiglottis - History and Exam HISTORY EXAM Sore throat Ill appearing Dysphagia/odynophagia Anxiety, “tripod position” Changing Voice Muffled voice Fevers Stridor, respiratory distress  Epiglottis - Evaluation Visualization Flexible Laryngoscopy (video) Careful with kids  Epiglottis - Additional Evaluation Xray ○ Not always necessary can be clinical diagnosis ○ Help differentiate ○ Findings: “Thumb Sign” - Enlarged epiglottis Loss of vallecular space Other workup ○ Labs ○ Blood Cx  Epiglottis - Management IV, O2, monitor Airway! ○ Consult anesthesia or ENT early ○ Advanced airway skills necessary Respiratory distress → Bag-valve-mask with 100% O2 ○ Intubate if BVM doesn’t maintain ○ Intubation ideally done in OR Cricothyroidotomy if intubation unsuccessful Antibiotics ○ Typically 3rd gen cephalosporins + vanco Steroids maybe?  “Laryngotracheitis” Croup - Overview Larynx and SUBglottic airway Sx: ____________________ and _____________________ Usually self -limited but can lead to airway obstruction Mostly viral Common in young kids Westly Croup score ________________ on Xray Often managed at home with cool steam Steroids, racemic epinephrine, supportive care if more severe  Croup - Etiology Usually viral: Parainfluenza virus (Most common) RSV, adenovirus Bacterial tracheitis: Staph/Strep Common in 6mo-3yrs but can occur outside this Peaks in fall-winter  Croup - History and Exam HISTORY EXAM Febrile, tachypnea, tachycardia Usually starts with congestion, Cough nasal discharge Accessory muscle use Fever Prolonged inspiratory phase “Barking cough” Stridor- attention to when Hoarseness Anxious/agitated Stridor Respiratory distress Fatigue, listless, retractions, decreased breath sounds Cyanosis/pallor  Croup - Evaluation Imaging ○ Usually NOT required - clinical dx ○ Soft tissue neck “ Steeple Sign” ○ Can help differentiate other causes Epiglottitis FB aspiration  Croup Severity: Westley Score Clinical Feature Score Level of consciousness Normal, including sleep = 0 Disoriented = 5 Mild (score 8): severe stridor at rest, With agitation = 1 severe retractions, child is anxious/ At rest = 2 agitated or pale/fatigued Air Entry Normal = 0 Impending respiratory failure (score >12): Decreased = 1 fatigue, listless, marked retractions, Markedly decreased = 2 decreased breath sounds, decreased LOC, cyanosis/pallor Retractions None = 0 Mild = 1 Moderate = 2 Severe = 3  Croup - Management Mild symptoms ○ Can often be managed at home - cool air, steam air often discussed ○ Single dose of steroids: Dexamethasone or prednisolone Moderate-Severe ○ Racemic epinephrine nebulizer ○ Single dose Dexamethasone (oral or IM) ○ Supportive care (humidified O2, tylenol, fluids) ○ Observe → disposition If improved can probably go home If persistent or worsening, admission Foreign Bodies Eye Ear Nasal Upper Airway  Foreign Body - Eye Usually superficial and benign Often metal, wood or plastic Sx of corneal FB: red eye, pain, photophobia, blurry vision, tearing, “Foreign body sensation” PE: ○ Visual acuity often normal ○ Dilated conjunctival blood vessels ○ Edema of lids, conjunctiva and/or cornea ○ May or may not see the actual FB with naked eye ○ Rust Ring: if metallic FB present more than a few hours Superficial Foreign Body - Eye: Management Assure no signs of penetration into globe Flip lid → look for other FB Anesthetize cornea: Tetracaine, Proparacaine Removal methods: ○ Irrigation ○ Cotton-tipped swab ○ Needle removal with 25-27g Tetanus! Antibiotics after removal +/- Burr drill for rust rings F/u with ophthalmology Foreign Bodies - Ear Canal Typically in kids < 6yo and special needs adults Beads, pebbles, small toys Present with ear pain and/or drainage Apparent on otoscopy Urgent removal for: ○ Button batteries (alkaline tissue necrosis) ○ Live insects (kill them first) ○ Penetrating FB (ENT consultation!) Qtips, pencils Can penetrate TM → hearing loss, vertigo Ear Canal Foreign Body - Removal Irrigation ○ Insects or small inorganic objects Katz Extractor ○ NOT button batteries, tympanostomy tubes/perforated TM, matter than can swell (bean) Alligator forceps Instrumentation ○ Can be painful. Sedation?? ○ Dermabond on end of wooden swab stick Bayonet ENT referral Forceps ○ If unable to remove ○ Glass or FB with sharp edges ○ FB wedged against TM Plastic or metal ear curette Foreign Bodies - Nasal Usually young children Often asymptomatic Beads, crayons, pebbles, candy Presentations ○ Purulent nasal discharge ○ Epistaxis ○ Nasal obstruction ○ Mouth breathing ○ Visualized on exam: nasal speculum and head lamp Nasal Foreign Bodies - Removal Button batteries - urgent removal Otherwise, removal is generally elective Positive pressure ○ Pt blows nose while occluding opposite nostril ○ Positive pressure by parent Instrumentation ○ Topical anesthesia ○ Sedation maybe? ○ Forceps, suction, ear curette, balloon catheter Foreign Bodies - Upper airway Most common in kids (esp < 2yo) ○ Peanuts, seeds, popcorn, small toys, coins, marbles, balloons Adults ○ Food, pin/nails, dental appliances Risk factors ○ Decreased LOC from head trauma, drugs/ETOH, stroke, dementia, Parkinson’s Presentations ○ Cough, choking, stridor, vocal changes, respiratory distress, cyanosis, AMS, asphyxiation Foreign Bodies - Management Imaging (only if stable) ○ Xray: (can miss radiolucent FB) ○ Coins align sagittally in tracheal, coronal plane in esophagus ○ CT neck if high suspicion and xray negative Direct visual with flexible direct laryngoscopy Heimlich maneuver O2, bag-valve-mask Intubation Cricothyroidotomy or tracheotomy Non-life-threatening FB ○ Can be removed by rigid bronchoscopy Direct Laryngoscopy Facial Trauma - Overview Common mechanisms ○ Sports, MVA, Assaults, Falls Consider other injuries! (neck, head) Exam: tenderness, swelling, bruising, dental malocclusion ○ “Battle’s Sign” ○ “Racoon eyes” Management: AIRWAY! Diagnostics: CT facial bones Treatment: Discharge with close f/u vs. urgent/emergent surgery Facial trauma - Anatomy  Facial Trauma - Assessment Initial assessment Important history questions ○ Blurred of double vision? ○ Assure airway patency → intubate if ○ Hearing intact? necessary ○ Can you breathe through both sides ○ Control hemorrhage with direct of nose? pressure ○ Are your teeth coming together ○ Suction for intraoral bleeding normally? ○ Pupil size and reactivity ○ Loose or painful teeth? ○ Other sites of trauma?  Facial Trauma - Exam Eyes: visual acuity, pupil size/reactivity, hyphema, corneal abrasion, rupture globe Nose: tenderness, crepitus, septal hematoma, CSF leak Midface: tenderness, swelling, ecchymosis, check for stability Mandible: tenderness, swelling, dental malocclusion, TMJ tenderness Mouth ○ Stridor, drooling, dysphonia, hematoma/hemorrhage ○ Lacerations, dental fractures, avulsions Ears: external laceration/hematoma, Battle’s sign, hemotympanum, CSF otorrhea Facial Trauma - Exam Facial Trauma - Exam Facial Trauma - Diagnostics CT facial bones - contrast? ○ Xrays lack sensitivity Consider additional imaging ○ Head and/or c-spine Mandible ○ CT or Panorex Facial trauma - Midface fractures “Tripod fracture” ○ Involves zygoma, lateral orbit, and maxilla ○ Caused by direct blow ○ Typically displaced and requires operative repair LeFort fractures ○ LeForte I: transferve fx through maxilla above roots of teeth ○ LeForte II: involves nasal bridge, maxilla, orbital floor ○ LeForte III: (craniofacial dissociation) - fx extends through nasal bridge, medial and lateral orbital walls, zygomatic arch, sphenoid (base of skull); may see CSF leak Facial Trauma - Mandibular fracture Nasal Trauma & Nasal Bone Fractures Nasal Bridge Fractures ○ Most commonly fractured bone ○ Crepitance, tenderness, or mobile bony segments on palpation ○ Xray initial imaging of choice if needed ○ R/O additional fractures on exam or imaging ○ Tx: Ice, OTC meds ○ If grossly displaced - consult ENT for reduction in first hours ○ If significant edema - Referral to ENT ○ No participation in competitive sports ~6 weeks Important to rule out… Septal Hematoma ○ Widening of anterior septum ○ Can lead to septal necrosis and infections ○ Treat with I&D, packing for 2-5 days, antibiotics  Facial Trauma - Ear Blunt vs penetrating trauma External and otoscopy evaluation ○ Consider CSF leak or hemotympanum Don’t forget about tetanus  Auricular Hematoma Auricular hematoma = blood accumulates btwn skin and cartilage of the external ear → “cauliflower ear” deformity if not evacuated Evacuate: Procedure ○ 18-g needle in some cases ○ Incision with clot evacuation ○ Compression dressing to avoid reaccumulation!  Ear Lacerations Need to consider if cartilage is involved ○ Will need layered closure if so Usually 5-0 sutures Auricular block Consider prophylactic antibiotics ○ Cover for perichondritis (pseudomonas coverage) → PO _____________ ○ Dog/cat bites → PO ____________________ Extra… penetrating neck trauma Location - divided into zones ○ Zone I: Clavicles/sternum to cricoid cartilage ○ Zone II: Cricoid cartilage to angle of mandible ○ Zone III: Superior to angle of mandible to skull area CTA!! Look at vasculature Extra… facial lacerations Forehead - frontalis muscle Eyelid - lacrimal system, eye involvement, lid involvement Cheek - parotid gland, parotid duct, and/or facial nerve Mouth - through and through, salivary glands, dental involvement, vermilion border, tongue Uptodate has great resources for facial lacerations! Eye/Orbital Trauma - Overview Common eye complaint What are some traumatic eye complaints you can think of? ○ Corneal abrasion ○ Foreign body ○ Hyphema ○ Lacerations ○ Subconjunctival hemorrhage ○ Open Globe ○ Orbital wall fracture  Eye Trauma: Physical Exam Talk through the steps of someone presenting with eye trauma  Orbital Wall Fractures Most commonly d/t blunt force ___________ wall is the thinnest and more frequently injured Orbit Fractures - Presentation Pain, swelling, tenderness, bruising Enophthalmos Orbital rim step-off Crepitus Infraorbital anesthesia (damage to what nerve???___________) Diplopia What exam is key to check for entrapment? Orbit Fracture - Evaluation and Management Imaging? _____________ R/O globe injury, nerve injury Consult ophthalmology Many discharged w/ close f/u unless complications like globe injury, entrapment, retrobulbar hematoma, other trauma Antibiotics often recommended  Cricothyrotomy Cricothyrotomy: Procedure placing a tube through incision in the cricothyroid membrane in order to establish an airway for oxygenation and ventilation Indications: “Can’t intubate can’t oxygenate” (CICO) Conditions: Hemorrhage, profound emesis, trismus, obstructing lesions, upper airway occlusion (foreign body, edema, anaphylaxis), trauma, congenital deformities One study found that of all clinical conditions requiring cricothyrotomy, 32 percent involved facial fractures, 32 percent blood or vomitus in the airway, 7 percent traumatic airway obstruction, and 11 percent failed intubation in the absence of other specified problem Tracheostomy A surgical procedure that creates an opening in anterior wall of trachea to facilitate airway access and ventilation Emergent ○ Acute upper airway obstruction ○ Patients who have undergone an emergent cricothyrotomy ○ Select fractures of oropharynx, face, and neck ○ Penetrating laryngeal trauma Elective ○ Prolonged mechanical ventilation ○ Patients with poor airway protection (neuromuscular disorders) ○ Severe OSA ○ Severe subglottic stenosis ○ Severe focal cord paralysis Wrap up for HEENT emergencies Airway. Airway. Airway Can have rapid deterioration when airway involved Many are clinical diagnoses If imaging is needed → plain films or CT scan Early involvement of specialist (ENT, anesthesiology, ophthalmology) if patients critically ill or not responding to usual treatment  Wrap up…What do these make you think about? Hot Potato, muffled Steeple Sign voice Do Not Miss w/ nasal fx Battle’s sign Thumb Sign Kiesselbach’s Plexus Oxymetazoline Seidel's sign Racemic Epinephrine Woody cellulitis in submandibular & submental space And don’t forget about…  Etiology S/S Dx Tx Epistaxis Anterior - many Anterior - Clinical Pressure, afrin, silver Posterior - ath./HTN Kiesselbach’s triangle nitrate, packing, embolization Peritonsillar Pharyngitis/tonsillitis Unilateral swelling, Clinical Needle asp. Abscess uvula deviation, US I&D muffled hot potato CT scan Antibiotics voice Possible admission Ludwig’s Angina Dental infection Muffled/hot potato Clinical IV antibiotics, admit most common voice CT scan to evaluate Woody edema extent Ill appearing Epiglottitis Children - bacteria Drooling, tri-pod Clinical Antibiotics (3rd gen Adults - bacteria/ position, Muffled voice, Xray - THUMB sign ceph. +/- Vanco) viral lll appearing Direct visualization Admission Non- infectious Croup Parainfluenza most STRIDOR, Barking Clinical Supportive; steroids, common cough Xray - Steeple sign racemic epinephrine