Term 4 Week 14 (w/c 3/12/12)
Thanks to our guest international editor last week. VF in a child is something that instills considerable anxiety and should always be planned for.
We couldn’t stop on week 13. It just seemed unlucky so we are going to make this the last week of term. We will start with our usual run around the classroom for everyone to add something. So we will welcome some new Tweets or Tweeters!
Which features of Down’s Syndrome cause difficulties for both anaesthesia and surgery?
The story this week:
A mother has brought her 18 year old son into Emergency Department. He has Down’s Syndrome. The presenting complaint is that he has an acute onset cough. He was seen with a pen and a pen top in his mouth whilst doing some drawing. He has told his mother he has swallowed the pen top when she has been out of the room.
What actions do we need to take now?
Examination of the airway reveals nothing. Respiratory rate is 16. Every time you encourage a deeper breath the boy coughs. On lying flat he becomes a little distressed because it causes even more coughing. However, if he stays sitting he is perfectly comfortable.
His tongue is a little large but he had some complex dental work under GA 3 years ago and was easily intubated with a nasal tube. His BMI has increased to 31 since that operation.
On auscultation you can hear a faint wheeze on the right.
CVS examination is unremarkable. There are no murmurs. The Saturations in air are 95. He has not had any cardiac problems and was structurally normal at birth.
ENT would like to do a rigid bronchoscope. What is your anaesthetic plan?
Planning a gas induction is an oft quoted idea which has a number of advantages and disadvantages which may or may not survive the actual event. Having a Plan B may be more important!
However, the mother of the patient is terribly distressed about her son going to theatre and does not want to consent to any medical actions until the boy’s father gets back form work away tomorrow morning. She thinks he is undistressed now whilst sat up and he will be calmer in theatre if he has his Dad with him.
How will you gain consent for the procedure?
There are no trick questions in #gasclass. It is an educational tool only. Everyone’s opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialties and you can send us a direct message if you would prefer to remain anonymous.