Oral Board Grab Bag Thread

[pgg]

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The epidural solves the issue of postop pain control.

So does a PCA, without the coagulopathy drama.

 

[PMPMD]

so whats the proper answer for the unable to ventilate?

The situation may require a change in positioning to relieve the obstruction - lateral decub or prone. However in the peri-arrest pt, going away from a supine position makes it harder to do chest compressions. I'm assuming there is no rigid bronch in the remote location. If you weren't in the rads suite, you could consider cannulating for CPB. Best option is to go back in time and keep pt spontaneous.

 

[Lee123]

Best option is to go back in time and keep pt spontaneous.

👍
What I did was topicalize the airway, took a direct look, intubated and let the patient breath herself down with Sevo. You could also breath down with a mask, but I was hesitant with the potential for a full stomach with the pain, nausea and biliary obstruction. Also, I did not like the fact I was in Specials.

 

[Robert Loblaw]

(honest) answer to the tonsils case:

i do not recall the specific etiologies of a split s2, other than to note that it connotes delayed closure of either the pulmonic or aortic valve--this could be due to increased flows on one side of the heart versus theother--for example, in the setting of a shunt--impaired emptying of either the RV or LV (in the setting of aortic or pulmonic stenosis, or interventricular conduction delay.

in any event, i would be concerned about the possibility of undiagnosed cardiac disease in this child and i would begin workup with an ekg. if the child were for T and A due to OSA, I would be especially concerned about the possibility of severe OSA causing pulmonary hypertension and right heart strain.

a holosystolic murmur would raise the possibility of a VSD, MR or TR, or PDA. if one arm were larger than the other my concern would be undiagnosed coarctation (?).

now let's go through the exercise: he undergoes uneventful T & A and an hour later he is bleeding profusely from the mouth, swallowing copious amounts of blood. he's rushed emergently to the OR. what is the induction plan?

 

[Idiopathic]

so whats the proper answer for the unable to ventilate?

its in your preparation, maintain spontaneous ventilation, inhalation induction, take over bag mask, if you can mask then usually the dynamic obstruction wont be that much of a problem, but consider having ENT or thoracic surgery at bedside with rigid bronchoscopy available, especially with a mass located that distally. Also consider cardiopulmonary bypass for complete failure to secure airway (if case has to be done)

fiberoptic scope/awake intubation wont be of any real benefit here, either. you could mention trying to advance a long thin ETT (like a 5.0) as far distally as possible, you may get it in the right mainsteam, but this would be more of a rescue.

 

[sevoflurane]

(honest) answer to the tonsils case:

i do not recall the specific etiologies of a split s2, other than to note that it connotes delayed closure of either the pulmonic or aortic valve--this could be due to increased flows on one side of the heart versus theother--for example, in the setting of a shunt--impaired emptying of either the RV or LV (in the setting of aortic or pulmonic stenosis, or interventricular conduction delay.

in any event, i would be concerned about the possibility of undiagnosed cardiac disease in this child and i would begin workup with an ekg. if the child were for T and A due to OSA, I would be especially concerned about the possibility of severe OSA causing pulmonary hypertension and right heart strain.

a holosystolic murmur would raise the possibility of a VSD, MR or TR, or PDA. if one arm were larger than the other my concern would be undiagnosed coarctation (?).

now let's go through the exercise: he undergoes uneventful T & A and an hour later he is bleeding profusely from the mouth, swallowing copious amounts of blood. he's rushed emergently to the OR. what is the induction plan?

👍

So if he shows up the day of surgery for T&A you would get an EKG? What would you be looking for?
Fixed splitting of S2 in this population is usually caused by an ASD.
What if the EKG was normal. Would you proceed?
What if you saw inverted P waves and the child is asymptomatic?
Would you proceed then?

Would you proceed if you suspected a VSD (holosystolic murmur)?

There are different ways to answer this question.
IMHO, the most important determinant of weather to proceed or not is if the child has symptoms. So you need to focus on history. You should approach all your answers this way... history and physical FIRST! 🙂

If the child is running around the playground, has been gaining weight normally, and isn't suddenly turning blue... then it's prudent to proceed as the ASD is likely a small restrictive defect. I wouldn't get an EKG.

If it's wide open, and they are getting recurrent infections, DOE, not growing appropriately, acrocyanotic spells, early signs of pulmonary HTN, etc.. then delay the procedure.

I don't remember if a PDA can cause limb hypoplasia...

I was going for radial aplasia/hypoplasia in VACETRL which would raise a red flag... which might get me to consider working up the patient instead of proceeding.

V - vertebral defects
A- anal defects
C- cardiac defects
T- tracheoseophageal fistulas
E- esophageal defects
R- renal and radial anomalies.
L- limb defects (commonly radial/thumb aplasia)

Remember, most secundum type ASD's close spontaneoulsy as the child growns and ASD's are relatively common in adults.


Either way... when answering this question mention extra care to bubble precautions to get some extra points.

Good luck to those getting ready to take the orals....

 

[sevoflurane]

 

[sevoflurane]

That was the pre-op scenario.

Here is the post-op scenario:

now let's go through the exercise: he undergoes uneventful T & A and an hour later he is bleeding profusely from the mouth, swallowing copious amounts of blood. he's rushed emergently to the OR. what is the induction plan?

 

[Robert Loblaw]

👍

So if he shows up the day of surgery for T&A you would get an EKG? What would you be looking for?
Fixed splitting of S2 in this population is usually caused by an ASD.
What if the EKG was normal. Would you proceed?
What if you saw inverted P waves and the child is asymptomatic?
Would you proceed then?

Would you proceed if you suspected a VSD (holosystolic murmur)?

There are different ways to answer this question.
IMHO, the most important determinant of weather to proceed or not is if the child has symptoms. So you need to focus on history. You should approach all your answers this way... history and physical FIRST! 🙂

If the child is running around the playground, has been gaining weight normally, and isn't suddenly turning blue... then it's prudent to proceed as the ASD is likely a small restrictive defect. I wouldn't get an EKG.

If it's wide open, and they are getting recurrent infections, DOE, not growing appropriately, acrocyanotic spells, early signs of pulmonary HTN, etc.. then delay the procedure.

I don't remember if a PDA can cause limb hypoplasia...

I was going for radial aplasia/hypoplasia in VACETRL which would raise a red flag... which might get me to consider working up the patient instead of proceeding.

V - vertebral defects
A- anal defects
C- cardiac defects
T- tracheoseophageal fistulas
E- esophageal defects
R- renal and radial anomalies.
L- limb defects (commonly radial/thumb aplasia)

Remember, most secundum type ASD's close spontaneoulsy as the child growns and ASD's are relatively common in adults.


Either way... when answering this question mention extra care to bubble precautions to get some extra points.

Good luck to those getting ready to take the orals....

Thanks for this...I do adult cardiac so the kids hearts question is stretching me a bit. My training algorithm was the following: CBC and lutes on t&a; any signs of resp acidosis (hco3) or polycythemia --> EKG. Any abnormalities on exam or EKG --> echo.

The purpose of this thread was to identify weak areas to buff prior to the exam so thanks for the question.

 

[Robert Loblaw]

In point of fact, can someone with the appropriate experience and expertise describe the classic peds murmurs one might encounter...still's, PDA, etc?

Thanks...

 

[sevoflurane]

Thanks for this...I do adult cardiac so the kids hearts question is stretching me a bit. My training algorithm was the following: CBC and lutes on t&a; any signs of resp acidosis (hco3) or polycythemia --> EKG. Any abnormalities on exam or EKG --> echo.

The purpose of this thread was to identify weak areas to buff prior to the exam so thanks for the question.

👍 Good workup plan.

I'm adult cardiac too... but whish I did more of the non-bread and butter little guys.

I still contemplate a pedi fellowship every now and again... 🙄

But once you get a taste of PP, it's hard going back. 😳