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PED-EM-L  August 2004

PED-EM-L August 2004

Subject:

a tough airway management case

From:

Martin Herman <[log in to unmask]>

Reply-To:

Martin Herman <[log in to unmask]>

Date:

Mon, 30 Aug 2004 14:05:01 -0500

Content-Type:

text/plain

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text/plain (123 lines)

Tough case indeed.
If the kid needed O2 and you couldn't oxygenate, then advanced airway
techniques would be required. You must be able to oxygenate and ventilate if
you are going to sedate. "when in doubt ...leave it out".

If you felt comfortable you could oxygenate and ventilate, you might have
relaxed the pt with some meds like versed and or fentanyl  and then try some
airway techniques to "buy" time till a definitive airway can be placed.
As mentioned
laryngeal mask is one option,
combitube is another.
Also consider
needle cricothyrotomy or surgical cric

I would reccomend Reviewing  the mangement of the difficult airway, and or
attending The National Airway Course.
Set up an advanced airway cart, to be prepared for the next difficult
airway.

Marty


-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]]On Behalf Of Rob Ojala
Sent: Sunday, August 29, 2004 5:40 PM
To: [log in to unmask]
Subject: Re: a tough airway management case


Great job in my humble opinion -and  I wouldn't sedate - despite the fact
that anxiety appeared to impede his mechanics/efficiency of breathing.
The dose of nebulised adrenaline we use in this age group would be 5mg.
We have access to senior paeds anaethetists who would be our first choice
for the airway - and if needle cric is required i suspect an EP might be in
the best position to perform this...ENT - perhaps they are best placed to
handle the more controlled theatre environment and a more definitive
solution.
my 2c
Rob Ojala

Dr R.A.Ojala FACEM
 Emergency Physician
The Emergency Department
Christchurch Hospital
Christchurch, NZ
Ph(03)3640270
[log in to unmask]
www.cdhb.govt.nz/ed/


>>> "Lisa Amir, MD, MPH" <[log in to unmask]> 29/08/04 23:13:38 >>>
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 wi!
th 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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