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Chapter 47. Management of a Child with a History of Difficult Intubation and Post-Tonsillectomy Bleed

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Which of the following devices would MOST likely be ineffective for airway management in a patient with post-tonsillectomy bleeding?

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A. direct laryngoscopy

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B. indirect laryngoscopy

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C. Trachlight

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D. awake bronchoscopy

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E. LMA with subsequent bronchoscopy-guided endotracheal intubation

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(D) Awake bronchoscopy is not an option as a child will unlikely be cooperative during this procedure and blood and secretions will impair the visualization of the glottis using the bronchoscope.

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What is the generally accepted preoperative management in severe post-tonsillectomy bleeding?

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A. History and physical, followed by rapid IV access with fluid resuscitation and operative revision under general anesthesia with endotracheal intubation.

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B. History and physical, followed by rapid IV access with fluid resuscitation and operative revision under sedation without endotracheal intubation, to avoid laryngospasm.

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C. Endotracheal intubation in the emergency room as soon as possible because of the risk of rapid swelling of the oropharynx.

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D. No operative intervention, as chance of spontaneous stop of bleeding outweighs the anesthesia risk (aspiration, difficult airway, etc.).

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E. History and physical, IV access and blood work, and elective operative revision as soon as the 6 hours NPO timeframe is reached because of risk of aspiration.

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(A) In general, rapid IV access with fluid resuscitation is necessary due to the unknown blood loss. Urgent operative revision under general anesthesia is often necessary.

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All of the following should be used with caution during post-tonsillectomy bleeding EXCEPT

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A. ketorolac

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B. dexamethasone

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C. ibuprofen

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D. morphine

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E. albumin 5%

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(E) If fluid resuscitation with crystalloids is not sufficient, a colloid solution and/or blood products are necessary to treat the hypovolemia.

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