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caligas

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I’m thinking fem-fem bypass from the picture, but maybe there is access for sedated trach.
 
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deleted162650

I'm curious if anybody on here has had experience with something like that. ECMO as the plan for a bad airway.

At the children's hospital where I did residency they had a young teen with an enormous mediastinal mass. They did an SAB followed by awake venous groin canulation and initiation of V-V bypass.
 
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vector2

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At the children's hospital where I did residency they had a young teen with an enormous mediastinal mass. They did an SAB followed by awake venous groin canulation and initiation of V-V bypass.

Med mass? You mean fem-fem V-A bypass, right?
 
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deleted59964

would be interesting to know how mobile that mass is, he is still eating so another view might give a more favourable picture. might be possible to gas him off to sleep.
 
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caligas

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Vector was saying you want v-a for massive mediastinal mass. But yes, v-v would suit here for oxygenation.
 

vector2

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why va? This is airway obstruction without heart failure? Surely vv would work or am I missing something?

I guess it really depends on the mass. VV for isolated tracheobronchial compression, VA for compression of great vessels/right heart with hemodynamic compromise that doesn't respond to lateral/prone positioning etc
 
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deleted59964

So for the bypass advocates - you go on bypass, then off to sleep, then secure airway, then come off bypass and give protamine?
 

partydoc

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So for the bypass advocates - you go on bypass, then off to sleep, then secure airway, then come off bypass and give protamine?

bypass, sleep, airway/surgical airway depending on anatomy
 
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deleted59964

I haven’t done bypass for a difficult airway.
You’d have to reverse the heparin before starting the dissection wouldn’t you?
 

Noyac

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Something about this kid tells me he would cooperate with an awake Trach. But he has obviously been able to eat through all of this. It appears to me that this mass is only involving his face above the mouth. He is probably breathing through his mouth. Therefore, an awake FOB may even be doable.

The key to this case and on the boards in my mind is not to burn your bridges. If that means having bypass ready to go then so be it. This case is obviously going to a high volume Children’s hospital and I’d bet good money someone there has done FOB on quite a few kids. That person does the airway.
 
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deleted59964

like all cases in kids, the age (and developmental age) of the child is important in choosing a plan.

he's 14yo, so he might be able to tolerate an awake fiberoptic after good topicalisation, if he was 4 that becomes highly unlikely.

most difficult airways in small children get gas to sleep with 100% O2 and sevo, maintain spontaneous ventilation, then either combined video laryngoscopy and fiberoptic, or LMA conduit for fiberoptic... of course have all your back up plans in place, especially for exams. (including bypass ... but in reality it takes time to run on to bypass, so I doubt in a child you have enough if you lose the airway unless you've already cannulated and the machine and personnel are ready).
 

CopaceticOne

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478303E500000578-5206871-X_rays_show_the_large_benign_mass-m-19_1513977711897.jpg
 
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Psai

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What's wrong with the back of his neck? Why is there a little black space there
 

Noyac

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Shiet that’s not a lot of space between the mandible and the manubrium.
Not in that study but I think he should be able to extend the cervical spine just fine. Or at least enough. I think one could slip an LMA in there and call it a day ;)
 

Noyac

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The skull thickness is impressive.
I saw that too. WTF?
This poor kiddo isn’t out of the woods when the mass is gone by a long shot.
I also thought that his c-spine was jacked (medical terminology) but I think it’s mostly that it’s not lined up well in the study.
 

pgg

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It’s not midline
Yeah I think that head is both turned and tilted. The cspine is mostly centered but that's about it.

The slice of the skull we're seeing is way off midline. The radiologist was probably letting a med student drive the mouse, I don't know why anyone would measure skull thickness in that view.
 

chocomorsel

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Guys, that’s his true skull thickness. If you read up on the illness, these patients bones get eaten up by fibrous tissue and they end up developing a lot of skeletal deformities.

The mass on his face stems from facial bones being replaced by fibrous tissue. It can affect one part of their body or many parts of it.

Read up guys. Can’t remember the name for the disease right this minute though.
 
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pgg

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Guys, that’s his true skull thickness. If you read up on the illness, these patients bones get eaten up by fibrous tissue and they end up developing a lot of skeletal deformities.

The mass on his face stems from facial bones being replaced by fibrous tissue. It can affect one part of their body or many parts of it.

Read up guys. Can’t remember the name for the disease right this minute though.

Wow

I figured the total lack of facial bones in that scan meant the scan plane was way off midline.
 

Onefellswoop87

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Guys, that’s his true skull thickness. If you read up on the illness, these patients bones get eaten up by fibrous tissue and they end up developing a lot of skeletal deformities.

The mass on his face stems from facial bones being replaced by fibrous tissue. It can affect one part of their body or many parts of it.

Read up guys. Can’t remember the name for the disease right this minute though.

"If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there."

So there is an issue with the facial bones or there isn't?
 
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deleted59964

Guys, that’s his true skull thickness. If you read up on the illness, these patients bones get eaten up by fibrous tissue and they end up developing a lot of skeletal deformities.

The mass on his face stems from facial bones being replaced by fibrous tissue. It can affect one part of their body or many parts of it.

Read up guys. Can’t remember the name for the disease right this minute though.
I don’t know what this child’s pathology is, and you are sadly probably right ... but whether this slice is midline is important ... this might be a slice taken to demonstrate maximal dimension of the mass to be excised.

For an example see
 
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chocomorsel

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Jobsfan,
I am NOT PROBABLY RIGHT. I am right. And yes, I know about the difference in appearance depending on where the slices are taken.

The condition is actually in the first linked article called polyostotic fibrous dysplasia. Look up X-rays of this condition.

Look at the bone density of the skull. You see the thinned bone/hollowed out areas that should appear completely uniform but aren't? As in should appear completely white/gray like in your example? Thats's because bone has been replaced and thickened by fibrous tissue.
 
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deleted59964

Jobsfan,
I am NOT PROBABLY RIGHT. I am right. And yes, I know about the difference in appearance depending on where the slices are taken.

The condition is actually in the first linked article called polyostotic fibrous dysplasia. Look up X-rays of this condition.

Look at the bone density of the skull. You see the thinned bone/hollowed out areas that should appear completely uniform but aren't? As in should appear completely white/gray like in your example? Thats's because bone has been replaced and thickened by fibrous tissue.
ok chill - you frighten me with your caps lock. you are right about the pathology.

the accuracy of the thickness of the skull measurement we can’t confirm unless you actually have the CT ... because it’s not midline.
 
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“After visiting Emanuel last night and observing a ray of hope from his pupillary reflexes and the muscle tone of his face, I was informed this morning that his condition had turned grave,”

Read more here: Cuban boy with giant tumor dies after surgery

Seems to me that quote clearly says the operation had its share of complications and “survival” through the surgery was a tad gray.
 
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