Indian Paediatrics & Critical Care

💎 Pearl 04

Difficult Intubation

✍️ Author: Dr. Ajay Kumar Saini

Definition of a physiologically difficult airway:

A physiologically difficult airway is where the patient has physiological characteristics that create a high chance of adverse events from the induction agents, ventilation or response to laryngoscopy, even though the laryngoscopy itself may be technically uncomplicated.

Contributing factors to the increased risk:

Risk of post-intubation hypoxia:
- Reduced capacity for denitrogenation/preoxygenation (delirium, respiratory arrest)
- Small FRC (obesity, pregnancy)
- Increased demand (sepsis, thyrotoxicosis)
Risk of cardiovascular collapse
- Any shock states, eg. hypovolemia, poor cardiac contractility, obstructive shock states
- Reduced cardiovascular reserve, eg. unrevascularised coronary artery disease
- Metabolic acidosis
- Pro-arrhythmic state, eg. severe electrolyte derangement
- Fragile aortic or cerebrovascular aneurysmal pathology
Risk of neurological injury
- Raised ICP, hypertensive crisis

Optimisation strategies

Correct hypovolemia and acidosis
Pre-empt vasodilation and reduced cardiac output on induction with pre-intubation introduction of vasopressors and inotropes
Specifically look for, and target, RV failure (eg. with pulmonary vasodilators and inodilators)
Preoxygenate with NIV/HFNP
Use lower doses of cardiostable induction agents like ketamine

💎 DTaP Pedia Pearl 3

DTaP Pedia Pearl 3

✍️ Author: Dr. Ajay Kumar Saini

🖼️ Bedside Clinical Flowchart / Radiology Image:

💎 Bedside Pearl

DFD

✍️ Author: Dr. Ajay Kumar Saini

💎 Bedside Pearl

IIN

✍️ Author: Dr. Ajay Kumar Saini

STATION 10

A previously healthy 6 year old female came with C/O fever for 2wk, and difficulty in breathing for last 3 days, on admission pt had tachycardia, tachypnoea with feeble femoral pulses and 2-D Echo show Dilated left ventricle with Ejection fraction <15%, BP in Upper limb was 134/96 while in Lower limb 72/54. A diagnostic imaging modality was done shown below in figure. Look at the figure and answer the following?

Marks

Q 1) What is this diagnostic imaging modality ? 1

Q 2) What is the arrow showing in above depicted picture? 1

Q 3) Identify the diagnosis ? 1

Q 4) Write any two differential diagnosis of above condition ? 0.5*2=1

Q 5) Write any one management option. 1

ANSWER KEY STATION 10

Ans. 1 ) 3-D reconstruction of CT AORTO-ANGIOGRAM

Ans. 2 ) Stenosed segment of descending thoracic aorta

Ans. 3 ) Takayasu arteritis – type II-III

Ans. 4 ) (any two)

· Aortic coarctation

· Atherosclerosis

· Behcet disease

· Giant cell arteritis

· Ig-G4 related disease

· Kawasaki disease

· Rheumatoid arthritis

· Sarcoidosis

Ans. 5 ) (any one)

Corticosteroid (high dose iv steroid)

Immunosuppressive therapy (methotrexate)

Surgical revascularization

Arterial reconstruction