I walked into the ICU yesterday morning to find a crowd of people around a bedside, the “crash cart” close by. While not an unfamiliar scene for anyone who works in the ICU, the patient I found in the room was not exactly what I was expecting- a 14 day old baby with coarctation of the aorta- who was admitted to the ICU overnight in heart failure. The baby had just self extubated and her oxygen saturation was falling quickly. There were several attempts to intubate her by the pediatrician at the bedside, but they were unsuccessful and the baby’s heart rate dropped into the 50s, necessitating CPR and atropine. The only laryngoscope we had was too big for the baby, but we needed to make due with what we had. There was a properly sized laryngoscope in the NICU, but that was 2 floors away and someone was trying to find it.
We mask ventilated the baby with difficulty, and I looked into the airway. The previous ETT had been too big and there was considerable edema and erythema in the larynx. Unable to visualize the vocal cords (which is very unusual for a baby), I blindly placed a smaller ETT, which barely fit through the vocal cords. By luck, the ETT was in the right place and the heart rate improved with oxygenation.
The baby will live another day, but for how much longer? Coarctation of the aorta should be corrected immediately after diagnosis at birth. This baby was 14 days old and going into heart failure and pulmonary edema. With no surgical resources, I questioned at the time if I should have even attempted to reintubate the child, and in other situations I would have chosen not to. In this case, there is a pediatric cardiac surgery team coming to Rwanda in 3 weeks. If we can keep the child alive until then, maybe she can be operated on. Tick, tock.