A 3-year-old child presents to the emergency department with acute onset of choking and stridor after playing with a peanut. Clinical examination reveals unilateral decreased air entry on the right side with inspiratory stridor. Rigid bronchoscopy is planned for foreign body removal. Which agent is the drug of choice for induction of general anesthesia in this case?

Explanation

## Drug of Choice for Induction in Foreign Body Airway Emergency **Key Point:** Ketamine is the agent of choice for induction in pediatric foreign body airway cases because it preserves airway reflexes and maintains spontaneous ventilation. ### Why Ketamine is Optimal **High-Yield:** Ketamine offers several critical advantages in foreign body airway management: 1. **Airway Reflex Preservation** — Maintains protective airway reflexes (cough, gag) better than other induction agents, reducing aspiration risk during rigid bronchoscopy 2. **Spontaneous Ventilation** — Allows continued spontaneous breathing, enabling the child to maintain oxygenation if the foreign body partially obstructs the airway 3. **Hemodynamic Stability** — Maintains or increases blood pressure and heart rate through sympathomimetic effects, crucial in a compromised airway 4. **Analgesia** — Provides analgesia in addition to anesthesia, beneficial for the traumatized child 5. **Bronchodilation** — Has inherent bronchodilator properties **Clinical Pearl:** Ketamine is the gold standard for induction in any emergency airway scenario with potential for aspiration or partial obstruction — foreign bodies, full stomach, or difficult airway anticipated. ### Comparison with Alternatives | Agent | Airway Reflex | Spontaneous Ventilation | Hemodynamics | Aspiration Risk | |-------|---------------|------------------------|--------------|------------------| | **Ketamine** | Preserved | Maintained | Stable/↑ | **Low** | | Propofol | Depressed | Depressed | ↓↓ | High | | Thiopental | Depressed | Depressed | ↓ | High | | Etomidate | Depressed | Depressed | Stable | High | **Mnemonic:** **SAFE-K** — **S**pontaneous ventilation, **A**irway reflexes, **F**ew side effects, **E**xcellent for emergency, **K**etamine ### Dosing in Pediatrics - **IV induction:** 1–2 mg/kg - **IM induction:** 4–5 mg/kg (if IV access unavailable) **Warning:** Avoid propofol and thiopental in foreign body airway — both suppress airway reflexes and spontaneous ventilation, increasing aspiration and hypoxia risk.