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Final clinical long case 66

Created: 16/2/2021
A 17-month-old male infant, weighing 10 kg, has been admitted to the paediatric ward. He was brought to A&E by his mother after she noticed grunting. Earlier, the baby had been eating “Bombay mix”, containing peanuts and cashew nuts, during which he had had a coughing fit and turned blue transiently. Later, he had settled and then continued to eat, having a banana and chocolates. Two hours later, the mother noticed grunting and brought the baby to A&E. On examination, the baby appears to be stable. His saturation is 94% on air. He is apyrexial. On auscultation, there are harsh breath sounds on the left side. Otherwise, there is nothing of note. The chest X-ray shows a hyperinflated right lung field with minimal midline shift.

1. Summarise the case.
2. What are the dangers of a vegetative foreign body?
3. How does a ball valve mechanism work?
4. What are the immediate, short-term and long-term complications?
5. What other investigations would you carry out and why?
6. Draw the pressure-volume and flow volume loop for this condition.
7. Would you operate immediately or wait for 6 hours? Why? What are the guidelines?
8. Would you use topical amethocaine (Ametop) or eutectic mixture of local anaesthetics (EMLA)? What are the advantages of each? What premedication would you use?
9. Would you use rapid sequence induction or inhalational induction? Why?
10. How would you ventilate the patient?
11. Name the different types of bronchoscopes.
12. What are the strategies for ventilating the patient during bronchoscopy? What are the advantages and disadvantages of each of them?
13. What would you give for intraoperative pain relief? What are the options for maintenance anaesthesia?
14. What postoperative complications do you anticipate?
15. What are the causes of postoperative stridor and how would you manage it?

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