another endo case

[caligas]

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6 yof, otherwise healthy with suspected achalasia presents for EGD by a solid endoscopist. Mask induction?

 

[pgg]

Mask induction?

Nope. 🙂

 

[Mac4]

Get an IV.

 

[gasdoc77]

Nope. 🙂

+1

 

[deleted126335]

+1

+2
Been real impressed with two near aspirations with achalasia. Very memorable

 

[BobBarker]

I had an aspiration and resultant bronchospasm with an RSI on a pt with achalasia awhile back.

 

[Planktonmd]

Not a good idea

 

[btbam]

Place IV with 50% N20 50% O2, RSI.

 

[HalO'Thane]

Place IV with 50% N20 50% O2, RSI.

The only caveat I may add with the n20 then PIV route is that some kids may not be too happy with the mask over their face if they are already worked up, especially if they have not received an anxiolytic premedication. If you are not prepared to do a mask induction with a volatile agent (which I would not do in this case) then sometimes I feel it is just easier to put the IV in preop and let them cry. You can always give versed once the IV is in.

 

[chmd]

The only caveat I may add with the n20 then PIV route is that some kids may not be too happy with the mask over their face if they are already worked up, especially if they have not received an anxiolytic premedication. If you are not prepared to do a mask induction with a volatile agent (which I would not do in this case) then sometimes I feel it is just easier to put the IV in preop and let them cry. You can always give versed once the IV is in.

Why not give oral midaz and then place iv?

 

[Planktonmd]

The oral Midazolam might take a while to work if the patient has achalsia and the esophagus is like a plastic bag full of fluid

 

[urge]

6 yo kids get ivs on the floor all over the world without issues...

 

[Dwindlin]

6 yo kids get ivs on the floor all over the world without issues...

This is what I was thinking. I put them in kids this age frequently in the back of the medic with no problems.

 

[caligas]

Im Ketamine?

 

[BobBarker]

Retrograde wire then inhalation induction.

 

[btbam]

Retrograde wire then inhalation induction.

 

[Libertas]

are people typically giving sedating premedications to patients whom they are going to do an indicated rapid sequence induction? I've heard both schools of thought from attendings on this.....but I have tried to avoid giving any midazolam/fentanyl/etc myself if I know I'm going to do a rapid sequence. Maybe in pediatrics its more indicated, though.

 

[pgg]

are people typically giving sedating premedications to patients whom they are going to do an indicated rapid sequence induction? I've heard both schools of thought from attendings on this.....but I have tried to avoid giving any midazolam/fentanyl/etc myself if I know I'm going to do a rapid sequence. Maybe in pediatrics its more indicated, though.

For the great majority of patients, a bit of midazolam or fentanyl won't obtund them to the point that they cant protect their airway. It's totally reasonable and safe to premedicate most people who have an RSI indication.

Generally, the ones you shouldn't premedicate for an RSI are the same patients you shouldn't premedicate anyway. 2 mg of midazolam or 100 mcg of fentanyl isn't going to make a non-NPO 22 yo with appendicitis aspirate. It might for the septic 80 yo with a SBO.

 

[alphaholic06]

Do you guys use intranasal versed?

 

[dhb]

Do you guys use intranasal versed?

intra rectal for kids if they can't have it po

 

[Hypenosis]

O.2 mg/kg of intranasal versed for kids is great if there's no time for PO. It burns a bit but they are sedated within a couple of minutes. It capsule be very helpful for placing an IV in this patient and it would be the method i would choose. Along with making your life easier, it will also make things a lot less traumatic on the kid.

Under no circumstance would i consider a mask induction for this patient.

 

[SexPanther]

1-2 mcg/kg intranasal precedex works beautifully w/o the risk of emergence delerium that comes w versed. Gotta give it ~30 min to work though; added benefit of some intraop analgesia.

 

[gasdoc77]

Retrograde wire then inhalation induction.

I particularly like this technique when the parents insist on being there at induction. At'll learn em.

 

[Hypenosis]

Intranasal precedex is also great, but as you stated, it takes longer to work. In pediatrics, versed decreases the risk of emergence delirium as does precedex.