I'd like any thoughts the group might have on this case.
A four year who one year previously suffered severe head trauma due to a MVA with prolonged intubation. A tracheostomy was eventually performed and the child suffers from severe subglottic stenosis. Two months ago he was decanulated and was at home with a pulse ox and supplemental O2 prn. According to the father he has slowly worsening stridor over a five day period and then presented to the ED. No fever or cough, no other sytemic complaints. He had no stridor at rest with 98% saturation and moderate intercostal and sternal retracions, no fever. He was triaged as semi-urgent and initially seen by a resident in 20 minutes. During the exam the child became extremely agitated, developed perioral cyanosis and marked inspiratory and expiratory stridor and was transferred to the resuscitation room. When I initially examined the child he was extremely agitated, thrashing around on the bed, with saturations of 75%; he refused all oxygen in any manner ( mask, canula, canula with cup, etc. We placed him on his grandfather (the father was too agitated to help) and we eventually calmed him sufficiently to take a nonrebreather mask with slow rise in his saturations to 95%. He received two inhalations in rapid succession of adrenaline 1 mg and budesonide 1 mg with some improvement in his respiratory distress. He appeared to have fallen asleep for several minutes and when he awakened he again became severely agitated, decreased saturations to 60-65% and had loss of bowel and bladder control with slow resolution of the episode with oxygen and calming by GF. He had two more episodes like this.
Concommitantly I consulted with the ENT and PICU docs who knew him and recommended fibroscopic intubation with heliox in the OR. Due to techinical difficuties (first year ENT resident who needed to wait for his attending, equipment in the adjacent adult hospital which needed to be transferred) it took about 40 minutes to get him upstairs. We discussed sedation agents but due to the concern that he might irreversibly obstruct his airway with loss of tone, it was decided not to administer ( We don't have heliox in the ED yet).
The denoument: in OR found to have 1mm diameter of trachea, unable to intubate, used LMA and tracheostomy performed.
Any management suggestions? Would you have administered a sedative and if so, what?
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