Name that difficult AW:

[sevoflurane]

Advertisement - Members don't see this ad

Just for fun:

1)

2)

3)

4)

5)

6)

7)

8)

 

[Eta Carinae]

1. scheuermann's disease

2. Treacher-Collins Syndrome

3. cleft lip and palate

4. Klippel-Feil syndrome

5. Turner Syndrome

6. Cornelia de Lange syndrome

7. Isolated micrognathia vs. Fetal Alcohol Syndrome

8. Hereditary angioedema- congenial C1-Esterase Inh def.

 

[Eta Carinae]

disclaimer: I've been out of clinical medicine for a year now, so many of those may be inaccurate.

Also, for patient #1, all I could see was the thoracic kyphosis. I'm not sure if there was a pectus excavatum or not from that picture.

 

[Eta Carinae]

actually not sure about #1...at all.

Nice thread, though. Like, really nice.

 

[Planktonmd]

None of these airways is difficult as long as I have my beloved fiberoptic scope 😀
They all get some kind of sedation proprtional to the degree of their mental ******ation and they all get awake fiberoptic intubation

 

[pgg]

3. cleft lip and palate

More than that I think, unilateral craniofacial stuff makes me think Goldenhar.


ETA - good set of guesses, I don't think I could get even half of those by the photos. I know I've seen pic #1 somewhere else before though. 🙂

 

[caspian]

hmmm

1)Spondyloepiphyseal dysplasia
2) Treacher Collins
3) hemicraniofacial microsomia
4)Klippel-Fiel
5) Turner syndrome
6)Cornelia De Lange
7)Pierre Robin syndrome
8)Miescher Granulomatous macrocheilitis

 

[caspian]

Really not sure about number 1 either, wish we had a coronal view!

7 was pretty tricky too. Mandibular deficiency and absent tragus lead me towards Pierre Robin...

 

[pgg]

I know I've seen pic #1 somewhere else before though. 🙂

Duchenne's

lordosis, winged scapulae

 

[sevoflurane]

Dang.... You all are some smart mothas out there. Answer key tomorrow morning. 👍

Here is #9)

 

[pgg]

Dang.... You all are some smart mothas out there. Answer key tomorrow morning. 👍

Here is #9)

Beckwith-Wiedemann?

anterior ear crease, umbilical hernia vs omphalocele, maybe even a bit of nevus flammeus between the eyebrows?

 

[dhb]

Wilms tumor = hemihypertrophy

 

[urge]

Duchenne's

lordosis, winged scapulae

That's what I thought. Is that a difficult airway?


pent sux tube..... cpr

 

[pgg]

That's what I thought. Is that a difficult airway?

Shouldn't be ...

pent sux tube..... cpr

 

[hoyden]

Have you ever used dex sedation for mentally ******ed and not cooperative for AFI?

Originally Posted by Planktonmd
None of these airways is difficult as long as I have my beloved fiberoptic scope
They all get some kind of sedation proprtional to the degree of their mental ******ation and they all get awake fiberoptic intubation

 

[Eta Carinae]

More than that I think, unilateral craniofacial stuff makes me think Goldenhar.

You're totally right! I completely skimmed over the unilateral part. Goldenhar fits the bill better. I would expect cleft lip/palate to be a midline defect.

ETA - good set of guesses,

Thank you.

 

[Arch Guillotti]

This approach doesn't make any sense to me. Seems like its more trouble than its worth to try and perform awake intubations on kids like this.

None of these airways is difficult as long as I have my beloved fiberoptic scope 😀
They all get some kind of sedation proprtional to the degree of their mental ******ation and they all get awake fiberoptic intubation

 

[Eta Carinae]

Beckwith-Wiedemann?

anterior ear crease, umbilical hernia vs omphalocele, maybe even a bit of nevus flammeus between the eyebrows?

I agree #9= BWS----> talk about difficult airway and periop mgmt
👍

 

[dhb]

Have you ever used dex sedation for mentally ******ed and not cooperative for AFI?

As someone once said on this forum: "Special K for special needs"

 

[Planktonmd]

This approach doesn't make any sense to me. Seems like its more trouble than its worth to try and perform awake intubations on kids like this.

Really?
So what is your approach?

Note that when I say "awake" I use the term very loosely.

 

[Arch Guillotti]

Really?
So what is your approach?

How about breathing them down, placing an LMA and fiberoptically intubating through the LMA?

 

[Planktonmd]

How about breathing them down, placing an LMA and fiberoptically intubating through the LMA?

Sure, on some of them, but some of these deformed kids will not be easy to ventilate with an LMA.
Actually what DHB mentioned would make sense here: good old Ketamine and FOB.

 

[Noyac]

Holy crap, now this is a good thread. I only know a couple of these and you guys already nailed those.

 

[hoyden]

As someone once said on this forum: "Special K for special needs"

Ketamine dart to get the IV access for dex sedation and then - AFI? Or just skip the dex altogether?

We did not have dex in our residency. And I have not used that in PP either. Ketamine IM does not last long.

Making theoretical reasoning for September - have seen a lot of dex mentioning in all oral prep books for AFI.

 

[caspian]

Definitely BWS for #9. Only Wilms syndrome with AW pathology.

Reconsidering Miescher's cheilitis for #8. I think Eta got it right with hereditary angioedema.

Lips seem too evenly enlarged for Miescher's and for this thread hereditary angioedema would make more sense.

Keep em coming sevoflurane!

 

[Arch Guillotti]

Sure, on some of them, but some of these deformed kids will not be easy to ventilate with an LMA.
Actually what DHB mentioned would make sense here: good old Ketamine and FOB.

Yes some of them will obstruct with an inhalational induction. They can also obstruct from sedation as well.

Ketamine seems OK as long as they are kept spontaneously ventilating and secretions don't get too bad.

I think "awake" is a very loose term because kids don't deal well with "awake" intubations. However, I don't know that I have ever done an "awake" intubation on a kid, much less a kid with craniofacial abnormalities.

 

[Noyac]

Yes some of them will obstruct with an inhalational induction. They can also obstruct from sedation as well.

Ketamine seems OK as long as they are kept spontaneously ventilating and secretions don't get too bad.

I think "awake" is a very loose term because kids don't deal well with "awake" intubations. However, I don't know that I have ever done an "awake" intubation on a kid, much less a kid with craniofacial abnormalities.

much less with mental ******ation!

 

[IlDestriero]

None of these airways is difficult as long as I have my beloved fiberoptic scope 😀
They all get some kind of sedation proprtional to the degree of their mental ******ation and they all get awake fiberoptic intubation

NONE of these kids, save possibly one (I don't remember which # it was) would need an awake fiber. They're not all even difficult airways. But I'm a pediatric anesthesiologist, you may feel free to disagree. Almost anyone can be intubated through an LMA, or nasally with the fiber. Asleep.

 

[Planktonmd]

"awake" in a mentally ******ed kid means (in my opinion) breathing spontaneously.
Each case is different and you should be able to tell which kid will be easy to ventilate by mask or LMA if you need to.
If in your assessment the kid can be ventilated by mask or LMA then you can allow your self a deeper level of anesthesia.
If you are good with FOB all you need is about 30 seconds.

 

[Arch Guillotti]

NONE of these kids, save possibly one (I don't remember which # it was) would need an awake fiber. They're not all even difficult airways. But I'm a pediatric anesthesiologist, you may feel free to disagree.

I haven't had to put any kids like this to sleep since being an attending, and I have no desire to.

I did do a few in residency though and we never did an "awake" intubation. We did have the benefit of a peds ENT guy on standby though.

 

[Planktonmd]

Yes some of them will obstruct with an inhalational induction. They can also obstruct from sedation as well.

Obstruction from inhalation induction is not the issue, your LMA might not fit in some of these kids.

 

[IlDestriero]

Obstruction from inhalation induction is not the issue, your LMA might not fit in some of these kids.

You'd be suprised. But, certainly, do what you are comfortable doing. Though most of these kids would probably bypass most hospitals. You never know in a bad emergency though.

 

[sevoflurane]

#10)

This one goes back to step 1, but is definately a red flag in pediatric anesthesia land. Took my attending and I about 1 hour to secure the AW of one of these kids.

 

[sevoflurane]

Beckwith-Wiedemann?

anterior ear crease, umbilical hernia vs omphalocele, maybe even a bit of nevus flammeus between the eyebrows?

Nice job PGG. You have a 1 hr. non compete clause on this thread cuz you are that good 😀👍.

 

[Eta Carinae]

#10 looks like Hunter syndrome

 

[caspian]

none of these kids, save possibly one (i don't remember which # it was) would need an awake fiber.

#4?

 

[sevoflurane]

#10 looks like Hunter syndrome

Way to step up to the mic and real nice job with your first list. On this one you are close... but not quite. 👍

 

[Eta Carinae]

#10 Hurler syndrome?

I always get those two confused. They're like twins to me.

😳

 

[jeesapeesa]

Way to step up to the mic and real nice job with your first list. On this one you are close... but not quite. 👍

hurler's? since hunter's wound be X linked....not many o girls affected.

 

[Planktonmd]

You'd be suprised. But, certainly, do what you are comfortable doing. Though most of these kids would probably bypass most hospitals. You never know in a bad emergency though.

It is not rocket science!
If the patient (child or adult) looks difficult to ventilate by mask ---> do not abolish spontaneous ventilation and use the technique you are most proficient with (for me it is FOB).

 

[caspian]

hurler's? since hunter's wound be X linked....not many o girls affected.

argh you beat me to it! haha


Apart from being X-linked, look at those eyes. Corneal clouding.

Not present in Hunters.

 

[Eta Carinae]

Way to step up to the mic and real nice job with your first list.

Thanks

(blush)

 

[Eta Carinae]

hurler's? since hunter's wound be X linked....not many o girls affected.

argh you beat me to it! haha


Apart from being X-linked, look at those eyes. Corneal clouding.

Not present in Hunters.

And I beat both of you to it. HA HA



J/K no competition here.

 

[caspian]

whoops, yes you did!

I seriously need to up my game here.

No competition, no competition 😉

 

[sevoflurane]

Nice Job SDN. Smart people out there. Extra props to the Med-Students nailing this stuff. 👍

1. DMD (not difficult AW, just a curve ball) pent, sux, tube, cpr
2. Treacher Collins (can't forgett that face)
3. Goldenhar (CT gives it away... as PGG states, one sided, Oculomandibular hypoplasia)
4. Klippel-Fiel (c-spine)
5. Turners (neck)
6. Cornelia De Lange (Unibrow gives it away)
7. Pierre-Robin (micrognathia + absent tragus)
8. C1-Esterase Deficiency
9. Beckwith-wiedemann (ant. ear crease, omphalocele, nevus flammeus)
10. Hurler's (AR not x-linked + cloudy corneas + macroglossia +hepatosplenomegaly xray)

You all rock.

This is the last one. It is actually a difficult AW from an SDN member... any one care to guess??? IN2B8R? 😛

http://blog.kjstyle.org/wp-content/uploads/2008/08/******.jpg

 

[Mister J]

awesome thread! thanks for putting this together.

 

[Noyac]

This is the last one. It is actually a difficult AW from an SDN member... any one care to guess??? IN2B8R? 😛

http://blog.kjstyle.org/wp-content/uploads/2008/08/******.jpg

Down's

 

[Noyac]

"awake" in a mentally ******ed kid means (in my opinion) breathing spontaneously.

Hey, our spat is over so don't misread this response. I respect you opinion but,
I don't consider a spontaneously breathing kid, mentally ******ed or otherwise, "awake". On the boards, awake doesn't mean "spontaneously breathing". So I'm wondering why you make the above statement?

My mentally ******ed kids that I do with an LMA for the case are not "awake". But your statement says that they are.

I would call your approach induction with spontaneous respirations and FOI. I don't even consider the ketamine dart induction an awake procedure. You will more than likely need more than the Ketamine to place the tube.

 

[hoyden]

Hey, our spat is over so don't misread this response. I respect you opinion but,
I don't consider a spontaneously breathing kid, mentally ******ed or otherwise, "awake". On the boards, awake doesn't mean "spontaneously breathing". So I'm wondering why you make the above statement?

My mentally ******ed kids that I do with an LMA for the case are not "awake". But your statement says that they are.

I would call your approach induction with spontaneous respirations and FOI. I don't even consider the ketamine dart induction an awake procedure. You will more than likely need more than the Ketamine to place the tube.

Would you use IM ketamine to obtain an IV access and then dex sedation for the topicalization of the AW and FI then?

 

[Planktonmd]

Hey, our spat is over so don't misread this response. I respect you opinion but,
I don't consider a spontaneously breathing kid, mentally ******ed or otherwise, "awake". On the boards, awake doesn't mean "spontaneously breathing". So I'm wondering why you make the above statement?

My mentally ******ed kids that I do with an LMA for the case are not "awake". But your statement says that they are.

I would call your approach induction with spontaneous respirations and FOI. I don't even consider the ketamine dart induction an awake procedure. You will more than likely need more than the Ketamine to place the tube.

You are right, "awake" is probably not the right word here so let's say spontaneously breathing and sedated.
Not necessarily under GA though.
This can be achieved as you know in many ways, Ketamine is just one of them and most of the time Ketamine is all you need to place the tube, or you can just do the FOB with Ketamine and once you see the cords spray lidocaine wait a few seconds then intubate.
You can even use a propofol infusion if you have an IV the trick is just to titrate gradually so you don't lose the airway.
Topical anesthesia and airway blocks are not helpful that much in this population and they cause too much fear and anxiety.