The case of the life-threatening mass 

WDWLT: GEMS July 2016

​A 2 year old boy is brought into resus. He is sitting on the trolley as shown.

He is tachypnoeic, tachycardic and has a soft stridor. He is left undisturbed in his chosen position, high flow oxgen is administered and an attempt is made to keep everyone calm! Anaesthetic support is summoned urgently and a quick resus CXR is obtained.

What is your diagnosis?

Answer: This is a mediastinal mass. It is a malignancy until proven otherwise. For the geeks amongst you, the following are all possibilities. The first two are the commonest.

• T cell lymphoblastic leukaemia/ lymphoma
• Hodgkins and Non-Hodgkins Lymphoma
• Germ cell tumours
• Neurogenic tumours e.g. neuroblastoma
• Thymoma
• Thyroid carcinoma

There are a number of benign causes as well including vascular lesions, fatty lumps and funny congenital cysts.

On arrival of the (fairly junior) ITU doctor the patient has a near respiratory arrest. It is night-time (of course) and the paeds anaesthetist is on their way in from home. The ITU registrar manages to pass an ET tube but appears completely unable to ventilate the child. With the child becoming increasingly cyanosed, is there anything else you could try?

Answer: You could try proning the child. This might just take some of the weight of the tumour off the tracheo-bronchial tree and allow you to get some air in. Passing the ET tube further in than usual may also help to bypass the obstruction. Send someone off to theatre to get kit (armoured tubes, double-lumen tubes etc) but do the above measures first – you might just save a life.

Beth Newstead