2 days after bih, a child developed respiratory distress and had scaphoid abdomen. Breath sounds were decreased on the left side. After bag and mask ventilation, ET tube was put and the maximal cardiac impulse shifted to the right side. What should be the next step in management?
This child with respiratory distress, scaphoid abdomen and decreased breath sounds on left side suggests a diagnosis of congenital diaphragmatic hernia. In this condition, a diaphragmatic defect allows herniation of intra abdominal contents into the chest. Bag and mask ventilation is contraindicated in this condition as it cause distention of stomach contents in the chest and impairs ventilation. In this patient, the shifting of the site of maximal cardiac impulse to right side after ET tube inseion and ventilation, suggest that ET tube was wrongly inseed into esophagus instead of trachea. SO the most appropriate next step is to confirm ET tube position and reinse it. Chest X ray cannot differentiate whether ET tube is inseed in trachea or esophagus as esophagus is situated just behind trachea. Treatment of CDH includes endotracheal intubation followed by ventilation with a rate of 40 to 60 breaths/min and lowest peak inspiratory pressures that allow for normal chest rise which inturn help to avoid pneumothoraces due to barotrauma to the hypoplastic lungs. Ref: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e chapter 14.
Confirm the position of endotracheal tube
Emergency surgery
Naso gastric tube inseion
Chest x-ray to confirm position of the endotracheal tube