PTA and airway

Q: A 42-year-old male is admitted to the ICU with a peritonsillar abscess (PTA). On exam, the patient is anxious, leaning forward, tripoding on the bedside table with head in a "sniffing position," drooling, suprasternal retractions, and respiratory distress. No stridor is present. Saturation is 98% on 2L NC Oxygen. On exam, deviation of the uvula to the opposite side is noted. What's your next step?

A) Intubate the patient STAT at the bedside

B) Call Emergent ENT consult and prepare for STAT OR-SUITE

C) Gave Broad-spectrum antibiotics, including anaerobes, STAT

D) Insert Central Line for anticipated IVF resuscitation

E) Insert an arterial line to obtain ABG

Answer: B

The patient has a compromised airway and appears to have an extremely difficult airway. Ideally, the patient should be intubated in the OR to deal with any complications. Additionally, if needed, Incision and Drainage (InD) can be performed simultaneously. 

Intubating at the bedside is not a prudent decision (choice A). If needed, and there is no luxury of time for OR, an extremely experienced anesthesiologist with a difficult airway cart backup should be called.

Securing the airway takes precedence over Antibiotics (choice C)

Making a patient lie in bed for central line insertion may compromise the airway (choice D). Patient is in the tripod and sniffing positions to maintain ventilation.

An arterial line can be inserted once the airway is secure (choice E).

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References:

1. Ono K, Hirayama C, Ishii K, Okamoto Y, Hidaka H. Emergency airway management of patients with peritonsillar abscess. J Anesth. 2004;18(1):55-8. doi: 10.1007/s00540-003-0211-7. PMID: 14991479.

2. Beriault M, Green J, Hui A. Innovative airway management for peritonsillar abscess. Can J Anaesth. 2006 Jan;53(1):92-5. doi: 10.1007/BF03021533. PMID: 16371615.