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-----Mensaje original-----
De: Luis Azpurua [mailto:[log in to unmask]]
Enviado el: Lunes, 30 de Agosto de 2004 10:40 p.m.
Para: 'Rob Ojala'
CC: [log in to unmask]
Asunto: RE: a tough airway management case

Agree with Rob.

By definition this is a difficult airway. It should be managed by the
most skilled person at the time and in the ideal setting just as you
did.
In this case I would not sedate the child until I'm ready to solve the
problem. That is in the OR. There was a great risk that once sedated in
the ED you couldn't keep open the airway. As you stated, this child has
a severe subglottic stenosis. Intubation was impossible, and finally
performed a tracheostomy.
As you did, I would try to keep the child as calm as possible. I suppose
that he was very afraid of the medical situation because of the previous
experience. Thus keeping him calm will help to improve the respiratory
symptoms until you finally solve the problem ASAP. But don't wait too
long, (an hour?) sometimes they crash before.

Luis Azpurua
Hospital Pérez de León
Caracas, Venezuela

-----Mensaje original-----
De: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] En nombre de Rob Ojala
Enviado el: Domingo, 29 de Agosto de 2004 06:40 p.m.
Para: [log in to unmask]
Asunto: 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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The URL for the PED-EM-L Web Page is:
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