Case Week 8 (w/c 21/11/11)
You are the resident on-call. It’s about 10pm at night and you get a call from the ENT team. They have seen a 4 year old child in the emergency department who has presented with a left submandibular swelling and they would like to take the child to theatre. What are your initial thoughts?
The child has had increased pain and swelling for 2 days. He was started on antibiotics and analgaesics. Clinically it is hot, red, swollen and painful.
He is saturating fine on air and not in respiratory distress. There is however some mild stridor on flexion of his neck. Examination of his chest is otherwise unremarkable.
Mouth opening and teeth are satisfactory. There is nothing discharging into the mouth. He doesn’t have IV access at them moment. Reasonably co-operative yet in a lot of pain. He last ate at 4pm.
What is your plan?
Lots of discussion on method of induction. You are now underway. Regardless of gas versus IV induction you are now in a position to take over ventilation. You can ventilate, with a bit of difficulty, but larynx displaced & view not good? Assuming the tube won’t just slip into the trachea what are you going to do? Will you use a neuromuscular blocker and which one? What other measures might be helpful?
Regardless of your choices so far you have induced anaesthesia and with the help of the surgeon secured an airway with a size 4 tube. The surgeons are now undertaking exploration.
They only manage to drain a little amount of pus like material from the superficial tissue plane but at the base it is indurated. This doesn’t turn out to be a short quick case of drainage of an abscess as was supposed earlier. It takes 2.5h for the surgeons to dissect and explore the area and it’s 3 O’clock in the morning now.
What are you thinking now?
This will be the final post for this case.
Any hospital could conceivably receive a child with this kind of problem. The urgency to deal with it will be entirely dependent on the airway assessment and the perception of obstruction risk.
Assuming that there is time to plan management, it is advisable to transfer to a hospital with an experienced anaesthetic and ENT / OMFS team. It goes without saying that a detailed history and examination as able is needed followed by IV access and movement to an operating theatre.
Abscesses in this region of the body may affect the movement and appearance of soft tissue thus making airway management especially including gas induction difficult. Direct laryngoscopy may also be diificult in terms of access as well as what you end up looking at. The view down a fibre optic scope may be particularly difficult to discriminate with everything swollen and red! The difficult airway trolley must be available.
The discussion of IV versus gas induction is dependent on experiences and often seems counter to textbook teaching. I would love to see the randomised trial of 1000 children with airway obstruction comparing technique A and B. But it’s not going to happen and therefore one needs the right person as well as the right technique.
There are three controllers of the airway. The patient, the anaesthetist, the surgeon. Once anaesthesia is induced the latter two need to have communicated in detail about Plan A then B then C and informed the team about the sequence.
The end result was a child with a secure airway at 0300. It would take a brave person to want to return airway care to the patient at this time.
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