think!! - darkhorse

[ArchivalUser]

A 37-year-old woman is transferred from an outside hospital to the medical intensive care unit with a painful neck mass that was diagnosed as a large arteriovenous malformation (AVM). She reports difficulty swallowing, breathing with physical exertion and states that in the past 10 days, the mass has enlarged in size tremendously. On physical examination of the patient while she is sitting comfortably in bed, she has a large 10cm diameter mass on her right neck, crossing the midline slightly. The mass extends from her mandible to her clavicle and is red in color and mildly pulsating to the touch. She has audible stridor but is not short of breath. A chest radiograph shows tracheal deviation. The patient is complaining of severe neck pain. The most appropriate intervention at this time is to

A. administer morphine for pain control
B. consult thoracic surgery urgently
C. emergently removal of the mass
D. give her sedation for anxiety
E. perform tracheal intubation

[ArchivalUser]

secure the airway, E.

[ArchivalUser]

I am thinking n thinking n --> A for her Pain or B?

[ArchivalUser]

well guess my Pt is gonna die.....!!!!
Is Stridor n tracheal deviation n enlarging mass, guess would be indications for intubation

[ArchivalUser]

secure the airway.

[ArchivalUser]

The correct answer is B. This patient has an impending airway catastrophe secondary to tracheal compression leading to obliteration. She requires a surgical consult to determine where, and in what manner she should have her airway secured. There is no issue of "if" this patient requires such an intervention.

Although the patient is in pain, giving intravenous morphine for pain control (choice A) or sedation for anxiety (choice D) will decrease her respiratory drive and muscle tone. In normal persons these is not a concern, but for this patient loss of pharyngeal tone may lead to total airway collapse.

Although the mass does need to be removed, because of the vascular nature of the tumor, emergency excision (choice C) is not possible without tremendous loss of blood, and possibly, inability to achieve hemostasis. These patients often undergo staged embolizations of the feeding arteries via interventional radiology and then have surgical removal of the relatively avascular tumor.

Although this patient requires a secured airway, simple tracheal intubation (choice E) is not appropriate. Once this patient is sedated, she will lose all airway tone and certainly be unable to be ventilated. Given the mass on her neck and tracheal deviation, she will almost certainly not be able to be intubated via simple laryngoscopy.

[ArchivalUser]

ohhh cool guess i wasnt that much off yeahhhh my Pt will live, n I need to stop doubting myself!!!!

[ArchivalUser]

hey ben)...u seem to be in a very good mood today

[ArchivalUser]

98% of the time I am always in a good mood, there are no benefits to being depressed or in lousy MOOD, gotta move on gotta move forward no matter what!!

[ArchivalUser]

i miss this question,i will be back after may 22th,i need to concentrate now little bit on my exam
good luck darkhorse.