Being minimally invasive, as you were, while you were establishing your back
up plan, was the safest option. Kudos to you!
Hind sight is 20-20, but if they loose consciousness, usually, these kids
CAN be oxygenated and ventilated past their subglottic obstruction, with
aggressive BVM. As Marty stated, minimal sedation with fentanyl and
midazolam may actually facilitate adequate BVM in an anxious preschooler.
This is also my choice of medications while planning a semi-awake
intubation, because they are reversible. Ketamine would be a reasonable
choice as well.
However, unlike our kiwi friend, Dr. Ojala, I have some reservations about
cricothyrotomy even being a viable option in this lad, especially if the
segment of subglottic narrowing is long. The ideal situation would still be
inhalational induction in the OR by a pediatric anesthesiologist and an
attempt at ETI, with a tracheostomy set up as standby.
If help from your consultants is delayed and you HAVE to intervene, you
could preemptively administer an aerosol of 3-4 ml of 4 % lidocaine in
preparation for a semi-awake intubation. You could add the lidocaine to the
adrenaline updraft. This will provide some topical airway anesthesia to
enable you to perform a "quick look" direct laryngoscopy in conjunction
with minimal sedation, without him coughing and gagging and worsening his
obstruction. If his glottis is easily visualized, you could then proceed
with an intubation attempt.
One small question.... Lisa, I am assuming that you deferred vascular
access so as not to agitate the lad further. Is that also why you opted for
budesonide updraft versus parenteral dexamethasone? For acute airway edema,
it was my understanding that dex. is the preferred option.
Incidentally, we have Heliox available in our ED. In conjunction with
adrenaline aerosols, this option is very helpful in similar situations i.e.
in children with extra thoracic airway obstruction that are decompensating.
Heliox tanks are relatively inexpensive. Good case study to convince your
hospital administration to make it available to you!! (Are you up in
Thanks for sharing the case.
Jay Pershad, MD
Department of Pediatrics
Division of Emergency Medicine
University of Tennessee Health Sciences Center
Le Bonheur Children's Medical Center
Pediatric Emergency Specialists, PC
Pediatric Sedation Specialists, PC
I'd like any thoughts the group might have on this case. We don't have
heliox in the ED yet).
The denouement: 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
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