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

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

A. direct laryngoscopy

B. indirect laryngoscopy

C. Trachlight

D. awake bronchoscopy

E. LMA with subsequent bronchoscopy-guided endotracheal intubation

(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.

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

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

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

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

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

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.

(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.

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

A. ketorolac

B. dexamethasone

C. ibuprofen

D. morphine

E. albumin 5%

(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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