Anesthesia Tech Saves My Arse

[Noyac]

Was mask inducing a 2yo. RN was attempting the IV, I usually give the RN's a stab at it in hopes that they will keep their skills or learn some new ones. My anesth tech was standing on the other side of the pt ready to assist with airway tools. It was a nasal intubation, so she had the tube, blade, Magils and Afrin all ready to hand off. Well the RN blew the IV which was ok except that right then the kid spasmed. I've never really had a kid do it this intensely. I knew it was real even tho the Sats were 80's (I think) but I knew they were dropping. Tech handed me the blade and tube and grabbed the kids hand, wrapped a tourniquet around the arm and slammed in an IV LICKITY SPLIT. I had already intubated because I knew that was all I had to work with. My next thought was to grab the atropine and give it IM in the tongue expecting Bradycardia from shoving the tube past the cords but it never happened. The whole situation was averted but it could have been bad. I just love it when people see the problem and jump into action.

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[criticalelement]

Was mask inducing a 2yo. RN was attempting the IV, I usually give the RN's a stab at it in hopes that they will keep their skills or learn some new ones. My anesth tech was standing on the other side of the pt ready to assist with airway tools. It was a nasal intubation, so she had the tube, blade, Magils and Afrin all ready to hand off. Well the RN blew the IV which was ok except that right then the kid spasmed. I've never really had a kid do it this intensely. I knew it was real even tho the Sats were 80's (I think) but I knew they were dropping. Tech handed me the blade and tube and grabbed the kids hand, wrapped a tourniquet around the arm and slammed in an IV LICKITY SPLIT. I had already intubated because I knew that was all I had to work with. My next thought was to grab the atropine and give it IM in the tongue expecting Bradycardia from shoving the tube past the cords but it never happened. The whole situation was averted but it could have been bad. I just love it when people see the problem and jump into action.

Not following you.
nurse blew the iv, kid spasmd and you intubated before placing the iv or the anesthesia tech placed the iv? and once the tube is in.. no need for atropine. you got something better.. OXYGEN..

 

[sevoflurane]

Was mask inducing a 2yo. RN was attempting the IV, I usually give the RN's a stab at it in hopes that they will keep their skills or learn some new ones. My anesth tech was standing on the other side of the pt ready to assist with airway tools. It was a nasal intubation, so she had the tube, blade, Magils and Afrin all ready to hand off. Well the RN blew the IV which was ok except that right then the kid spasmed. I've never really had a kid do it this intensely. I knew it was real even tho the Sats were 80's (I think) but I knew they were dropping. Tech handed me the blade and tube and grabbed the kids hand, wrapped a tourniquet around the arm and slammed in an IV LICKITY SPLIT. I had already intubated because I knew that was all I had to work with. My next thought was to grab the atropine and give it IM in the tongue expecting Bradycardia from shoving the tube past the cords but it never happened. The whole situation was averted but it could have been bad. I just love it when people see the problem and jump into action.

Ha! Say hi to her for me... Very good at sneaking in some Java at the right time. A good anesthesia tech is worth their weight in gold.

 

[Noyac]

Not following you.
nurse blew the iv, kid spasmd and you intubated before placing the iv or the anesthesia tech placed the iv? and once the tube is in.. no need for atropine. you got something better.. OXYGEN..

Correct. You are not following me.

 

[Noyac]

Ha! Say hi to her for me... Very good at sneaking in some Java at the right time. A good anesthesia tech is worth their weight in gold.

She rocks. And believe it or not we swooped her out from under another dept all for our own benefit because they didn't have any idea what they had. Trained solely by us and loyal to the end.
Java runs are just lagniappe.
For those that are not Cajun, lagniappe is a term in south La which means, a little something extra.

 

[WholeLottaGame7]

Correct. You are not following me.

I think the point is that in this case the crisis was averted when you got the tube in, not because of the tech's ability to get the IV, which is fair.

However, the other point also remains that not every (or many) laryngospasms can be treated by just ramming the tube home, and if you couldn't then that IV would have been huge for a variety of reasons.

It's nice to have support staff that are actually useful (actually have skills and know when and where to use them even without asking). Especially if you do a lot of off-site stuff where you don't have many anesthesia personnel, having a little mini-RN/CRNA can be a lifesaver.

 

[btbam]

IM Sux might have been handy too.

 

[Noyac]

It's nice to have support staff that are actually useful (actually have skills and know when and where to use them even without asking). Especially if you do a lot of off-site stuff where you don't have many anesthesia personnel, having a little mini-RN/CRNA can be a lifesaver.

Actually, this is the point. I did not post this to talk about how to treat the situation. ****, every CA-1 should know how to handle laryngospasm within their first month of training.

Yes, btbam. IM sux would have been the next step if I was unsuccessful with the tube. That's not the point here.

Criticalelement, what I think you were missing is that the atropine was my next thought because after ramming a tube in a young child (2yo not being all that young) it is very common for the vagus to kick into overdrive and they can become very bradycardia or asystolic. Rare but possible.

 

[btbam]

How is your tech so good with IVs? Does she get to practice often at your hospital?

 

[IlDestriero]

I don't treat laryngospasm with forcing the tube into the trachea through closed cords, I treat it with IM sux in the deltoid. It takes about 30-60 seconds to work, while you are waiting, just continue to optimize the airway, maybe put in an OPA, etc and keep the positive pressure going with 100% O2.
I understand that's not the point, but I'm not sure "ram it home, big boy!" is the best move in a child desaturating and likely in laryngospasm.

 

[fakin' the funk]

Well this topic got weird real fast.

I think it's worth a mention that good techs, the kinds that anticipate, prepare, have experience, are flexible and teachable, save lives (or help us save lives, if you prefer that wording)

Bad techs IME aren't usually bad because of inexperience or lack of dexterity, but because of attitude: lazy/apathetic or occasionally passive-aggressive or some other behavioral thing.

 

[risnwb]

Do those of you who work alone typically have a tech with you at critical points? I work md only and our setup is such that we always have the RN assisting during induction and extubation etc... our tech turns over, gets airway equipment, makes Aline's setup, gets ultrasound for blocks etc, but never has direct patient contact or functions as an assistant as described here. Is this typical or is the tech described above simply way better and more knowledgeable than most?

 

[Random Anesthesiologist]

At my institution, our RTs are fantastic like this.

 

[IlDestriero]

Do those of you who work alone typically have a tech with you at critical points? I work md only and our setup is such that we always have the RN assisting during induction and extubation etc... our tech turns over, gets airway equipment, makes Aline's setup, gets ultrasound for blocks etc, but never has direct patient contact or functions as an assistant as described here. Is this typical or is the tech described above simply way better and more knowledgeable than most?

Our techs are like this as well, mostly turnover and runner work. Another anesthesiologist and I have planned some lectures and we are going to do some airway and trauma sims with them to make them more useful when the stool hits the fan. They're an underutilized resource in an emergency late night and on the weekend when it's the skeleton crew.
When we are really alone and unafraid at the ASC, we've no techs anyway, so we rely on the OR nurses or, gasp, the surgeons!

 

[urge]

If this would have been at my hospital the nurse would have written an incident report about the tech touching a patient and the union would have gotten her fired.

That is quality care.

 

[Arch Guillotti]

I don't treat laryngospasm with forcing the tube into the trachea through closed cords, I treat it with IM sux in the deltoid. It takes about 30-60 seconds to work, while you are waiting, just continue to optimize the airway, maybe put in an OPA, etc and keep the positive pressure going with 100% O2.
I understand that's not the point, but I'm not sure "ram it home, big boy!" is the best move in a child desaturating and likely in laryngospasm.

I agree, I would give IM sux and maybe atropine.

I would not want want to rely on a tech getting an IV and ramming a tube home wouldn't be my first choice either. I give IM drugs in the deltoid, not the tongue.

Sounds like your nurse poked the kid in stage 2.

 

[pgg]

Our help is the periop RN, if not busy chatting or charting. Occasionally a surgeon.

IlDestriero surely remembers his Navy days where the anesthesia techs were Corpsmen who got some OJT, and then as soon as they learned the job, moved someplace else and got replaced by newbies. Our techs stock the carts but don't do much more.

At the moonlighting gig the techs are career techs and great with retrieving and setting up equipment, but they don't touch patients.


I draw up succ and atropine any time I have a small kid. I've wasted untold volumes of succ and atropine over the years, but if I need it, I don't want to have to let go of the airway (and thereby abandon other maneuvers which could be laryngospasm-breaking) for 20-30 seconds to get it ready, and then wait longer for it to work IM.

 

[caligas]

Is there any technique to giving im sux in the tongue beyond what common sense would dictate? Ive heard inject it under the tongue inside the mouth.

 

[ZzzPlz]

Look at the big ass veins on the underside of your tongue in the mirror. That's where I'd inject if I used the tongue. But I'd probably go IM personally. Oh wait injecting the tongue is an IM injection.

 

[risnwb]

I've never even heard of giving it in the tongue haha, maybe I'll try rectal sux the next time I'm in a pinch

 

[Ezekiel2517]

damn you have a badass tech. I'm happy if the suction's hooked up

 

[Laryngophed]

damn you have a badass tech. I'm happy if the suction's hooked up

Depends on the place in our system, but this. Some of the techs are awesome and stop by in the morning while I'm setting up the room and ask if I need anything special in the room, make sure I have all of the supplies for the days cases, and just generally take care of me. And some days I walk into a room with a "case" still running from the day before and no new circuit to be found and have to set up from scratch. C'est la vie, I suppose.

 

[Arch Guillotti]

Criticalelement, what I think you were missing is that the atropine was my next thought because after ramming a tube in a young child (2yo not being all that young) it is very common for the vagus to kick into overdrive and they can become very bradycardia or asystolic. Rare but possible.

Is it common or rare?

 

[btbam]

I have only seen a vagal response from the act of laryngoscopy itself, not actually placing the tube through the cords...only ever with a straight blade, never with a Mac. Seen it probably half a dozen times in 3 years of doing peds full time. As for IM Sux, I just think it's easier to jam it in the deltoid rather than fumbling around with opening the kids mouth and trying to inject into the base of their tongue. As for which route works faster, I am not sure.

 

[propadope]

How deep was the kid during IV access? One can get fooled that you have passed through Stage 2 quickly when in reality it has yet to come.

Has anyone had success with stimulating the 'laryngospasm notch' as described by Larson in breaking a spasm?

 

[dhb]

Has anyone had success with stimulating the 'laryngospasm notch' as described by Larson in breaking a spasm?

Yes in adults, haven't tried in kids.

 

[Korba]

I don't treat laryngospasm with forcing the tube into the trachea through closed cords, I treat it with IM sux in the deltoid. It takes about 30-60 seconds to work, while you are waiting, just continue to optimize the airway, maybe put in an OPA, etc and keep the positive pressure going with 100% O2.
I understand that's not the point, but I'm not sure "ram it home, big boy!" is the best move in a child desaturating and likely in laryngospasm.

Agreed. I just can't see how forcing a tube through closed cords is in any way helpful.

 

[Noyac]

How is your tech so good with IVs? Does she get to practice often at your hospital?

Yes, we let her place them from time to time. It ends up being mostly pedi cases.

 

[Noyac]

Do those of you who work alone typically have a tech with you at critical points? I work md only and our setup is such that we always have the RN assisting during induction and extubation etc... our tech turns over, gets airway equipment, makes Aline's setup, gets ultrasound for blocks etc, but never has direct patient contact or functions as an assistant as described here. Is this typical or is the tech described above simply way better and more knowledgeable than most?

Big hospital has the tech
Surgery center, no tech.

 

[Noyac]

Is it common or rare?

Depends on the practitioner. I've seen it happen twice with one pedi fellow so for her it was common. But I've never had it happen therefore it's rare for me.

 

[urge]

Depends on the practitioner. I've seen it happen twice with one pedi fellow so for her it was common. But I've never had it happen therefore it's rare for me.

Could it be that she does more peds cases?