Another airway case

[freedeshaun2021]

Created a throwaway account for this, because I've already asked for input from several people at my institution and it would be pretty easy to ID me:

Carrying the airway/trauma pager earlier this week. Get a page about "Level 1 trauma, GSW". I go down to the ED and I see dozens of people around the trauma bay, and a teenage male sitting up in a stretcher, blood pouring from his mouth. He has a GSW that entered in his R tonsil and exited the R external auditory canal. The trauma resident has a fistful of kerlix in the guy's mouth and is holding pressure to the R side of his oropharynx. She says "I have a pulsating artery just under my finger". He's apparently lost at least 400cc so far. They just gave 1U and are hanging another. The kid looks panicked but is able to nod yes/no.

The kid's vitals are as follows: HR 125, BP 98/60, RR 30, SpO2 98%. The trauma attending says "anesthesia, you're doing this one".

Discuss.

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[Hork Bajir]

Sounds like a surgical airway if I’ve ever heard of one. Awake perc trach and move on with the primary survey...

 

[Arch Guillotti]

Created a throwaway account for this, because I've already asked for input from several people at my institution and it would be pretty easy to ID me:

Carrying the airway/trauma pager earlier this week. Get a page about "Level 1 trauma, GSW". I go down to the ED and I see dozens of people around the trauma bay, and a teenage male sitting up in a stretcher, blood pouring from his mouth. He has a GSW that entered in his R tonsil and exited the R external auditory canal. The trauma resident has a fistful of kerlix in the guy's mouth and is holding pressure to the R side of his oropharynx. She says "I have a pulsating artery just under my finger". He's apparently lost at least 400cc so far. They just gave 1U and are hanging another. The kid looks panicked but is able to nod yes/no.

The kid's vitals are as follows: HR 125, BP 98/60, RR 30, SpO2 98%. The trauma attending says "anesthesia, you're doing this one".

Discuss.

For future reference just pm me or pgg and either one of us will post it anonymously.

The trauma resident may be slightly panicked. However, it is not appropriate to just dump the airway responsibility as described. Take a deep breath, assess the situation and figure out what to do (securing the airway in the ED vs. the OR). The native airway is probably easy, put the kid to sleep and go for broke. Mark the cricothyroid membrane beforehand, numb it up, put a catheter in, whatever you need to do. I would actually do a DL vs glide scope. Surgical airway if intubation fails. Also, where is the ED attending in all of this?

 

[FiO2@21]

For future reference just pm me or pgg and either one of us will post it anonymously.

The trauma resident may be slightly panicked. However, it is not appropriate to just dump the airway responsibility as described. Take a deep breath, assess the situation and figure out what to do (securing the airway in the ED vs. the OR). The native airway is probably easy, put the kid to sleep and go for broke. Mark the cricothyroid membrane beforehand, numb it up, put a catheter in, whatever you need to do. I would actually do a DL vs glide scope. Surgical airway if intubation fails. Also, where is the ED attending in all of this?

Someone told me once that level 1 traumas are within the purview of anesthesia and surgery, that EM doesn’t play a role in them. But I’ve never verified this.

 

[Arch Guillotti]

Someone told me once that level 1 traumas are within the purview of anesthesia and surgery, that EM doesn’t play a role in them. But I’ve never verified this.

Probably depends on the institution more than anything. Where I trained EM normally handled the airways. I only remember one time that the CA-3 had to do the airway and the ED folks weren't happy but it wasn't a big deal.

 

[turnupthegas]

awake surgical airway.

 

[freedeshaun2021]

Probably depends on the institution more than anything. Where I trained EM normally handled the airways. I only remember one time that the CA-3 had to do the airway and the ED folks weren't happy but it wasn't a big deal.

Yes, that is the case here. EM handles the airway and we don't intervene, unless specifically directed to by the trauma lead or the EM resident.

Here's some more info:

The primary and secondary surveys have been done, this is the only injury. I inspect the kid's mouth with a flashlight (trauma resident's fingers still holding gauze to R oropharynx). There is oozy blood in the posterior pharynx, but he's coughing it out and maintaining his sats. I ask him to follow some simple commands (give me a thumbs up, etc) and he's cooperative.

After the first unit, his BP and HR are stable, the second unit was never started.

The ED resident tells me "we were thinking RSI with ketamine and glidescope".

What do you guys think?

 

[nimbus]

Yes, that is the case here. EM handles the airway and we don't intervene, unless specifically directed to by the trauma lead or the EM resident.

Here's some more info:

The primary and secondary surveys have been done, this is the only injury. I inspect the kid's mouth with a flashlight (trauma resident's fingers still holding gauze to R oropharynx). There is oozy blood in the posterior pharynx, but he's coughing it out and maintaining his sats. I ask him to follow some simple commands (give me a thumbs up, etc) and he's cooperative.

After the first unit, his BP and HR are stable, the second unit was never started.

The ED resident tells me "we were thinking RSI with ketamine and glidescope".

What do you guys think?

Oozy is better than spurting. If it’s an otherwise normal looking airway, DL is your best shot.

 

[coffeebythelake]

Yes, that is the case here. EM handles the airway and we don't intervene, unless specifically directed to by the trauma lead or the EM resident.

Here's some more info:

The primary and secondary surveys have been done, this is the only injury. I inspect the kid's mouth with a flashlight (trauma resident's fingers still holding gauze to R oropharynx). There is oozy blood in the posterior pharynx, but he's coughing it out and maintaining his sats. I ask him to follow some simple commands (give me a thumbs up, etc) and he's cooperative.

After the first unit, his BP and HR are stable, the second unit was never started.

The ED resident tells me "we were thinking RSI with ketamine and glidescope".

What do you guys think?

Why ketamine? He isn't unstable.

Why glidescope? If it looks otherwise like a reassuring airway I would just DL. Nothing like blood and secretions obscuring your video look

Agree with having a look at neck anatomy in case u need surgical airway. But in an oozing not hemorrhaging gsw doubtful it is needed

 

[Volatile]

He’s stable-ish. Take him to the OR. Don’t **** around with these airways in the ED. Have him prepped for a surgical airway (gen surg or ENT ready to go). Have TWO suctions available, yours and whatever the surgeons were gonna use. He’s oozing so it’s probably not going be that challenging. I would put him to sleep and DL. Have a VL available, sometimes they aren’t helpful if heavy bleeding or vomiting. If you want to look cool use a lightwand, I used them a couple times during deployment with bloody airways.
Use lots of propofol for induction, when the systolic goes to 50 there’s a lot less bleeding during your DL

 

[gaspasser127]

The ED resident tells me "we were thinking RSI with ketamine and glidescope".

What do you guys think?

classic. No disrespect to our EM colleagues because they have to deal with a lot of crap from nearly every admitting and consulting service in the hospital and they’re great at managing a whole host of acute conditions but this is where our training and comfort with difficult airways comes in handy.

people who don’t regularly intubate patients think the glidescope is always the answer in a “difficult” airway situation but obviously a bloody airway is only going to obscure your view on a video laryngoscope. DL is my best friend in these situations (if not a surgical airway in extreme circumstances).

An induction dose of ketamine is going to worsen secretions and make your view even less ideal. You could of course pre-treat with some glycopyrrolate.

Given that the patient is HDS and airway appears patient at this time, best thing to do is bring this patient to the OR and consult ENT for an awake trach.

 

[vector2]

Do this in the OR- if not for the airway difficulty then for the hemodynamics.

Had an experience similar to this where the ED induced and successfully intubated a guy shot in the face with a steady trickle of blood coming from the nose with a lot going down into his oropharynx too. Unlike your case OP, this patient did not show signs of much blood loss and his BP was normal to high at presentation. Inductions for the ED where I’m at are cookie cutter etomidate/sux most of the time. And of course after their intubation the ED totally falls asleep at the wheel when it comes to sedation, analgesia, and BP control.

So of course after this guy gets intubated with no propofol, fentanyl, lidocaine and no drips ready and waiting, his BP goes to 240, he pops the clot, and blood starts absolutely pouring from his nose and mouth. Luckily the ETT was already in but it turned a stable situation into a more critical one.

 

[GassYous]

Well first of all you start with "Look trauma, my name is Dr. freedesahun2021"

ED resident listened to too many podcasts about dsi or whatever the induction technique du jour is. Prop sux tube. Agree with OR since he is stable and too many ******* wannabe cooks in the kitchen.

 

[Arch Guillotti]

induction dose of ketamine is going to worsen secretions and make your view even less ideal. You could of course pre-treat with some glycopyrrolate.

Given that the patient is HDS and airway appears patient at this time, best thing to do is bring this patient to the OR and consult ENT for an awake trach.

Ketamine can worsen secretions but no way it happens enough to interfere with your view.

I think awake trach is a recipe for disaster.

 

[freedeshaun2021]

Ok, so here's what I did:

Called my attending to come down--load the boat. I told everyone to calm down, and that we had a few minutes to work with.

I wanted to keep the kid awake and sitting up, and didn't want to remove the occlusion to the artery, so I ditched the DL/VL option and decided to look with fiberscope. I had the kid lean forward as much as possible so the blood was running out of his mouth and not down the throat.

I quickly did the airway blocks --SLNx2, GPN (unilateral-- obviously wasn't able to get the R GPN), and transtracheal. With the trauma resident still holding occlusion in the R mouth, I had the EM resident hold a yankahuer to the L oropharynx (confirmed gag reflex ablated) and took a look with the fiber. First look I was able to see cords briefly before some blood splattered, occluding the view. Came out, wiped off scope and repeated again. Same thing second time-- still a few mL's of blood in the periglottic areas that got onto the camera. Third look-- I put the scope in the posterior pharynx and asked the kid to give a voluntary cough. This cleared the blood from around the glottis and I was able to get in. Confirmed tracheal rings and carina. Kid had good tube tolerance and didn't gag/cough. This whole process took about 5 minutes.

The rest of the story: after getting the tube, I let the ED give him that ketamine, and we took him to CT scan--packing still in place in his mouth. CTA head/neck showed a bleeding tonsillar branch of facial artery. He went to IR for embolization-- did well. He was actually extubated the next day.

I know the fiberscope is not a great choice with a bloody airway, but in this case I thought I would have the chance for more than one look since I kept him spontaneous and upright.

My backup plan would have been trauma team prep the neck, and tried an awake Lightwand (like Volatile suggested) with the patient in the lateral recovery position to allow the blood to drain out. If unsuccessful first try-- cut the neck.

I didn't think there was enough time to assemble the ENT team and get to the OR (I wasn't sure if we would be seeing arterial blood squirting out again soon). In retrospect, this could have been a good option as well.

 

[IlDestriero]

We would do that in the OR with ENT standing there with a trach tray open. I’d use a MAC3 Storz VL.
Otherwise treat it like a bleeding tonsil set up.
As noted you want a good balanced anesthetic as a hypertensive spike will ruin your evening pretty quickly and you’ll end up with a slash trach. And blood on your shoes.
Retrograde wire might be an option, but you don’t want the wire wandering into who knows what via the GSW injury.

 

[Katheudontas parateroumen]

Eek. At first this sounds like awake trach written all over it. I cannot be certain that the artery isn't gonna just start squirting blood when they let go of pressure. Sure it's oozing now but i'm sure once they let go who knows what will happen. I would ask the trauma surgeon/ENT for awake trach in the OR as my first go around. If they say no for whatever reason, as he is currently stable enough, go to the OR, preoxygenate with HFNC if available, double suction available, and RSI. CMAC is my choice as I can DL or VL as needed. Trach set up right next to the patient.

 

[Hork Bajir]

@Arch Guillotti care to share your reasoning as to why awake trach is a bad choice here?

 

[Katheudontas parateroumen]

Ok, so here's what I did:

Called my attending to come down--load the boat. I told everyone to calm down, and that we had a few minutes to work with.

I wanted to keep the kid awake and sitting up, and didn't want to remove the occlusion to the artery, so I ditched the DL/VL option and decided to look with fiberscope. I had the kid lean forward as much as possible so the blood was running out of his mouth and not down the throat.

I quickly did the airway blocks --SLNx2, GPN (unilateral-- obviously wasn't able to get the R GPN), and transtracheal. With the trauma resident still holding occlusion in the R mouth, I had the EM resident hold a yankahuer to the L oropharynx (confirmed gag reflex ablated) and took a look with the fiber. First look I was able to see cords briefly before some blood splattered, occluding the view. Came out, wiped off scope and repeated again. Same thing second time-- still a few mL's of blood in the periglottic areas that got onto the camera. Third look-- I put the scope in the posterior pharynx and asked the kid to give a voluntary cough. This cleared the blood from around the glottis and I was able to get in. Confirmed tracheal rings and carina. Kid had good tube tolerance and didn't gag/cough. This whole process took about 5 minutes.

The rest of the story: after getting the tube, I let the ED give him that ketamine, and we took him to CT scan--packing still in place in his mouth. CTA head/neck showed a bleeding tonsillar branch of facial artery. He went to IR for embolization-- did well. He was actually extubated the next day.

I know the fiberscope is not a great choice with a bloody airway, but in this case I thought I would have the chance for more than one look since I kept him spontaneous and upright.

My backup plan would have been trauma team prep the neck, and tried an awake Lightwand (like Volatile suggested) with the patient in the lateral recovery position to allow the blood to drain out. If unsuccessful first try-- cut the neck.

I didn't think there was enough time to assemble the ENT team and get to the OR (I wasn't sure if we would be seeing arterial blood squirting out again soon). In retrospect, this could have been a good option as well.

Wow that's impressive. I don't think I would have the guts to do that. Nice job! Notwithstanding I've never done those airway blocks before, definitely wouldn't be trying it for the first time here. Are most of you guys on here comfortable with those blocks?

 

[vector2]

Ok, so here's what I did:

Called my attending to come down--load the boat. I told everyone to calm down, and that we had a few minutes to work with.

I wanted to keep the kid awake and sitting up, and didn't want to remove the occlusion to the artery, so I ditched the DL/VL option and decided to look with fiberscope. I had the kid lean forward as much as possible so the blood was running out of his mouth and not down the throat.

I quickly did the airway blocks --SLNx2, GPN (unilateral-- obviously wasn't able to get the R GPN), and transtracheal. With the trauma resident still holding occlusion in the R mouth, I had the EM resident hold a yankahuer to the L oropharynx (confirmed gag reflex ablated) and took a look with the fiber. First look I was able to see cords briefly before some blood splattered, occluding the view. Came out, wiped off scope and repeated again. Same thing second time-- still a few mL's of blood in the periglottic areas that got onto the camera. Third look-- I put the scope in the posterior pharynx and asked the kid to give a voluntary cough. This cleared the blood from around the glottis and I was able to get in. Confirmed tracheal rings and carina. Kid had good tube tolerance and didn't gag/cough. This whole process took about 5 minutes.

The rest of the story: after getting the tube, I let the ED give him that ketamine, and we took him to CT scan--packing still in place in his mouth. CTA head/neck showed a bleeding tonsillar branch of facial artery. He went to IR for embolization-- did well. He was actually extubated the next day.

I know the fiberscope is not a great choice with a bloody airway, but in this case I thought I would have the chance for more than one look since I kept him spontaneous and upright.

My backup plan would have been trauma team prep the neck, and tried an awake Lightwand (like Volatile suggested) with the patient in the lateral recovery position to allow the blood to drain out. If unsuccessful first try-- cut the neck.

I didn't think there was enough time to assemble the ENT team and get to the OR (I wasn't sure if we would be seeing arterial blood squirting out again soon). In retrospect, this could have been a good option as well.

Kudos......to the trauma resident who kept his hand in the kid’s mouth the whole time while you embarked on this odyssey of airway blocks and fiberoptic tomf*ckery.

 

[freedeshaun2021]

Wow that's impressive. I don't think I would have the guts to do that. Nice job! Notwithstanding I've never done those airway blocks before, definitely wouldn't be trying it for the first time here. Are most of you guys on here comfortable with those blocks?

I'm at a program where we do the blocks for almost every AFOI. We do a ton of AFOI's semi-electively for our neurosurgery patients. I'd say 50% of our ACDF's get AFOI with airway blocks.

This is mostly because we have neuro anesthesia faculty who are very comfortable with alternate airway techniques, so our neuro rotations are also 'airway management' rotations. Lightwands, AFOI, intubating LMA's, etc...

 

[Lidolover]

1st attempt: OR, two suctions, RSI, DL (not too different than a bad bleeding tonsil)
If fails, retrograde intubation

if pt desaturating and in trouble, would not hesitate to place an LMA to tamponade the injury (I know sounds crazy with on open wound, but what would be the worst case scenario?) and then cric.

obviously there are multiple ways this can be done. I feel in such scenarios, fiberoptic intubation can help if you are lucky enough. But still u don’t loose anything except for time and inconvenience for the patient.

 

[WheezyBaby]

Someone told me once that level 1 traumas are within the purview of anesthesia and surgery, that EM doesn’t play a role in them. But I’ve never verified this.

Entirely facility dependent

 

[deleted547339]

classic. No disrespect to our EM colleagues because they have to deal with a lot of crap from nearly every admitting and consulting service in the hospital and they’re great at managing a whole host of acute conditions but this is where our training and comfort with difficult airways comes in handy.

people who don’t regularly intubate patients think the glidescope is always the answer in a “difficult” airway situation but obviously a bloody airway is only going to obscure your view on a video laryngoscope. DL is my best friend in these situations (if not a surgical airway in extreme circumstances).

An induction dose of ketamine is going to worsen secretions and make your view even less ideal. You could of course pre-treat with some glycopyrrolate.

Given that the patient is HDS and airway appears patient at this time, best thing to do is bring this patient to the OR and consult ENT for an awake trach.

Uhhhh....all do respect, this is why I get worried when we get a rotating anesthesiologist - having someone who first trauma primarily is great, having someone who still considers themself the end-all be all airway expert while only doing total hips.....

If you have a bleeding trauma patient with a HR>120, I would not consider that patient hemodynamically stable.

 

[Ronin786]

Uhhhh....all do respect, this is why I get worried when we get a rotating anesthesiologist - having someone who first trauma primarily is great, having someone who still considers themself the end-all be all airway expert while only doing total hips.....

If you have a bleeding trauma patient with a HR>120, I would not consider that patient hemodynamically stable.

Show me a teenager who's been shot through the face with a HR less than 120.

 

[kidthor]

OP - Awake FOI sounds reasonable and you pulled it off nicely. I'm surprised you did this well in the trauma bay, which is a foreign environment.

I'd have done the airway in the OR with an RSI then DL vs Glide vs ENT trach for backup. But again your way is another great option.

Sadly where I am the ED would have likely induced the patient and then lost the airway. That's how they roll where I am, and no disrespect to ED people out there. It's just that some of them have a hubristic need to go for broke.

 

[chessknt]

Show me a teenager who's been shot through the face with a HR less than 120.

And how would you discern anxiety/pain from progressing hemorrhagic shock in this case?

 

[woopedazz]

preoxygenate with HFNC if available

I'd be opposed to HFNC in a head-up patient with a known vascular injury, Pre-O2 might be difficult with their hand in the mouth, but probably not worth jetting air into what is still potentially a carotid. Same goes for the LMA option if there's other modalities/techniques available and we're not circling the drain just yet.

 

[GassYous]

Uhhhh....all do respect, this is why I get worried when we get a rotating anesthesiologist - having someone who first trauma primarily is great, having someone who still considers themself the end-all be all airway expert while only doing total hips.....

If you have a bleeding trauma patient with a HR>120, I would not consider that patient hemodynamically stable.

lmao look at this joker. Stay in your lane buddy, especially when you don't know what you're talking about.

 

[Katheudontas parateroumen]

I'd be opposed to HFNC in a head-up patient with a known vascular injury, Pre-O2 might be difficult with their hand in the mouth, but probably not worth jetting air into what is still potentially a carotid. Same goes for the LMA option if there's other modalities/techniques available and we're not circling the drain just yet.

Do you think air embolism is a high possibility in this situation with HFNC? I’m just worried about oxygenating this patient before inducing. Risk vs benefit. But thankfully this patient was oxygenating fine before airway intervention. But I didn’t think about that. Will definitely consider it in the future.

I think the OP did a great job. I don’t think a trach is a sign of a loss and from the look at things seems like what many of us would have suggested. But to avoid the trach and ability to do this AFOI is a win. In these in between kind of cases where there appears to still be some time, the least invasive attempt is definitely reasonable. But it does feel like playing with fire. I’ve done a few bleeding tonsils in residency so far but they were all relatively low risk, nothing like an arterial bleed like this one. Tough case.

 

[coffeebythelake]

Uhhhh....all do respect, this is why I get worried when we get a rotating anesthesiologist - having someone who first trauma primarily is great, having someone who still considers themself the end-all be all airway expert while only doing total hips.....

If you have a bleeding trauma patient with a HR>120, I would not consider that patient hemodynamically stable.

A lot of **** talk from someone who didn't even share a plan

 

[Southpaw]

Uhhhh....all do respect, this is why I get worried when we get a rotating anesthesiologist - having someone who first trauma primarily is great, having someone who still considers themself the end-all be all airway expert while only doing total hips.....

If you have a bleeding trauma patient with a HR>120, I would not consider that patient hemodynamically stable.

You get worried when you have a rotating anesthesiologist? In the ED? When I rotated there in residency I didn't touch the trauma room or an airway, but I definitely 'moved the meat' for my 19 shifts or so. I always felt that was kind treatment seeing that when EM rotated on my service they weren't expected to do anything other than work on airway skills the entire month. Care to guess who I think got the better end of that bargain? My guess is a couple of those EM guys now think they're better at the airway than me, all because of the glidescope. Whatever.

I don't care what your trauma survey or algorithm tells you. This kid has an intact airway and so long as volume in equals volume out it'll stay that way for the time being. This patient is best served by being brought to the OR urgently with a good skilled surgeon and an anethesiologist who'll induce when access is appropriate, all equipment and supplies are available, and everyone is ready with a plan of DL primary and surgical airway as backup.

You start etomidate succ'ing or ketamine succ'ing this kid in the trauma bay and you're causing more harm than good IMO. Risk/benefit isn't there.

 

[deleted547339]

You get worried when you have a rotating anesthesiologist? In the ED? When I rotated there in residency I didn't touch the trauma room or an airway, but I definitely 'moved the meat' for my 19 shifts or so. I always felt that was kind treatment seeing that when EM rotated on my service they weren't expected to do anything other than work on airway skills the entire month. Care to guess who I think got the better end of that bargain? My guess is a couple of those EM guys now think they're better at the airway than me, all because of the glidescope. Whatever.

I don't care what your trauma survey or algorithm tells you. This kid has an intact airway and so long as volume in equals volume out it'll stay that way for the time being. This patient is best served by being brought to the OR urgently with a good skilled surgeon and an anethesiologist who'll induce when access is appropriate, all equipment and supplies are availalbe, and everyone is ready with a plan of DL primary and surgical airway as backup.

You start etomidate succ'ing or ketamine succ'ing this kid in the trauma bay and you're causing more harm than good IMO. Risk/benefit isn't there.

Yes, I get worried. And the comments above are offensive. Have you not seen Ricky Bobby? Saying “no offense” before an offensive stament doesn’t make it not offensive. You don’t know know our average day or workflow. Spending a couple weeks in the ED as a med stud or resident isn’t a decent sample size. Further, I wasn’t talking crap, I was just pointing out there is a huge difference in anesthesiologists. We rotate trauma airways with anesthesia. I’ve seen more than one patient that was a little more tachy than I like get a big slug of prop then code by some CA2/CA3 who was too big for their britches. I generally only see attending anesthesiologists when patients crump in pacu (sometimes my patients board there) - let’s just say there seem to variable competency levels.

As far as my plan goes, I really wish I could see exactly where the holes are and see the patient (is he mega-fat/does he have a neck) First thing I would do is 1) mark the neck 2) give some product and 50 mcg fent 3) gather supplies and 4) talk him down. I have no idea how they have an EBL on someone who was shot outside the hospital, so I don’t believe that, especially given his vitals. I think you give this guy a big dose of anything and he codes. I would give the patient a yanker and ask them to suction their pharnyx as much as possible if he’s agreeable. I agree, this is urgent/emergent, but this isn’t push drugs and go since he’s not dying in front of you. I think from there you have a few options. If the wound is high end and the surgical resident is providing actual tamponade and you can fit a blade in the mouth, I think RSI isn’t crazy. My biggest concern with RSI here is that you aren’t going to be able to BVM if not immediately intubated, but that’s why you have the neck marked. Honestly, I’d consider having him hold a cmac blade if he could and taking a look at what I see with the bronchoscope.

 

[teacher2md]

Yes, I get worried. And the comments above are offensive. Have you not seen Ricky Bobby? Saying “no offense” before an offensive stament doesn’t make it not offensive. You don’t know know our average day or workflow. Spending a couple weeks in the ED as a med stud or resident isn’t a decent sample size. Further, I wasn’t talking crap, I was just pointing out there is a huge difference in anesthesiologists. We rotate trauma airways with anesthesia. I’ve seen more than one patient that was a little more tachy than I like get a big slug of prop then code by some CA2/CA3 who was too big for their britches. I generally only see attending anesthesiologists when patients crump in pacu (sometimes my patients board there) - let’s just say there seem to variable competency levels.

As far as my plan goes, I really wish I could see exactly where the holes are and see the patient (is he mega-fat/does he have a neck) First thing I would do is 1) mark the neck 2) give some product and 50 mcg fent 3) gather supplies and 4) talk him down. I have no idea how they have an EBL on someone who was shot outside the hospital, so I don’t believe that, especially given his vitals. I think you give this guy a big dose of anything and he codes. I would give the patient a yanker and ask them to suction their pharnyx as much as possible if he’s agreeable. I agree, this is urgent/emergent, but this isn’t push drugs and go since he’s not dying in front of you. I think from there you have a few options. If the wound is high end and the surgical resident is providing actual tamponade and you can fit a blade in the mouth, I think RSI isn’t crazy. My biggest concern with RSI here is that you aren’t going to be able to BVM if not immediately intubated, but that’s why you have the neck marked. Honestly, I’d consider having him hold a cmac blade if he could and taking a look at what I see with the bronchoscope.

How would you plan to instrument the airway if he’s not sedated? Would you do the blocks or some other technique?

I also would not want to lean him back to look with a VL... the trickle of blood coming out of the mouth would quickly become a puddle around the glottis if he were supine.

Maybe you could try VL with him upright, but I’ve never tried that before.

 

[Lidolover]

It’s easy to point out difficult moments for each specialty. To the best of my knowledge, I have only witnessed 2-3 crics and they all happened in the ED after arrogant ED residents thought they have the airway and anesthesia was never called....

 

[abolt18]

Yes, I get worried. And the comments above are offensive. Have you not seen Ricky Bobby? Saying “no offense” before an offensive stament doesn’t make it not offensive. You don’t know know our average day or workflow. Spending a couple weeks in the ED as a med stud or resident isn’t a decent sample size. Further, I wasn’t talking crap, I was just pointing out there is a huge difference in anesthesiologists. We rotate trauma airways with anesthesia. I’ve seen more than one patient that was a little more tachy than I like get a big slug of prop then code by some CA2/CA3 who was too big for their britches. I generally only see attending anesthesiologists when patients crump in pacu (sometimes my patients board there) - let’s just say there seem to variable competency levels.

As far as my plan goes, I really wish I could see exactly where the holes are and see the patient (is he mega-fat/does he have a neck) First thing I would do is 1) mark the neck 2) give some product and 50 mcg fent 3) gather supplies and 4) talk him down. I have no idea how they have an EBL on someone who was shot outside the hospital, so I don’t believe that, especially given his vitals. I think you give this guy a big dose of anything and he codes. I would give the patient a yanker and ask them to suction their pharnyx as much as possible if he’s agreeable. I agree, this is urgent/emergent, but this isn’t push drugs and go since he’s not dying in front of you. I think from there you have a few options. If the wound is high end and the surgical resident is providing actual tamponade and you can fit a blade in the mouth, I think RSI isn’t crazy. My biggest concern with RSI here is that you aren’t going to be able to BVM if not immediately intubated, but that’s why you have the neck marked. Honestly, I’d consider having him hold a cmac blade if he could and taking a look at what I see with the bronchoscope.

I think we all can recollect a few colleagues in our own specialties in whom we have little trust. Without a doubt there would be extreme variability in the management of this patient between anesthesiologists, as well as between EM docs. Some of them would be better and smoother than others. Some of them would likely be total chaos and more likely to end this in a bad outcome.

I've seen an EM resident push a huge dose of etomidate and midazolam to intubate a GCS 7 trauma patient who was already tachy/soft BP. Patient coded immediately. After getting ROSC and coding again, then ROSC, then coding again, he eventually died. I don't extrapolate this experience to mean that all or most EM docs are going to do the same.

 

[Volatile]

Simmer down peeps We have all seen good and bad medicine from every specialty. We are all fraannnds

 

[chocomorsel]

I think we all can recollect a few colleagues in our own specialties in whom we have little trust. Without a doubt there would be extreme variability in the management of this patient between anesthesiologists, as well as between EM docs. Some of them would be better and smoother than others. Some of them would likely be total chaos and more likely to end this in a bad outcome.

I've seen an EM resident push a huge dose of etomidate and midazolam to intubate a GCS 7 trauma patient who was already tachy/soft BP. Patient coded immediately. After getting ROSC and coding again, then ROSC, then coding again, he eventually died. I don't extrapolate this experience to mean that all or most EM docs are going to do the same.

The question is, where was his or her attending? Standing there allowing those doses of drugs?

 

[abolt18]

The question is, where was his or her attending? Standing there allowing those doses of drugs?

A question for the ages.

 

[CodeBlu]

Sounds like a bleeding tonsil in peds. Didn't read any of the above stuff.


If easy looking airway....
100% Fio2, Ketamine 40, prop 10mg aliquots, midaz 2. Hang another bag of blood. Activate MTP.
Double suction. DL with manual in line cuz trauma patient, uncleared c-spine etc.
IF you want to maintain spontaneous ventilation... skip the paralytic, but you're gonna make it harder on yourself...

The obvious safe option here is a perc-trach... I would consider it, but I'm also worried that with an internal carotid injury that doing a perc trach could lead to other disastrous things if he has an occult c-spine injury.

I vote going from above first and then going through the neck. I would prefer to do this in the OR than the ED trauma bay if time permits.
Plan A: DL/VL of some sort. If the bleeding gets out of control and I can't see... good old friend bougie and miller blade.
Plan B: Cric with a 6.0. Once tube is in.... sedate deep don't hate.... paralyze and tell whoever's holding pressure not to move their finger.

 

[Vivid_Quail]

Sounds like a bleeding tonsil in peds. Didn't read any of the above stuff.


If easy looking airway....
100% Fio2, Ketamine 40, prop 10mg aliquots, midaz 2. Hang another bag of blood. Activate MTP.
Double suction. DL with manual in line cuz trauma patient, uncleared c-spine etc.
IF you want to maintain spontaneous ventilation... skip the paralytic, but you're gonna make it harder on yourself...

The obvious safe option here is a perc-trach... I would consider it, but I'm also worried that with an internal carotid injury that doing a perc trach could lead to other disastrous things if he has an occult c-spine injury.

I vote going from above first and then going through the neck. I would prefer to do this in the OR than the ED trauma bay if time permits.
Plan A: DL/VL of some sort. If the bleeding gets out of control and I can't see... good old friend bougie and miller blade.
Plan B: Cric with a 6.0. Once tube is in.... sedate deep don't hate.... paralyze and tell whoever's holding pressure not to move their finger.

What is the difference in indication between a cric and an awake trach in this situation? I know the anatomy difference but just wondering why both have been mentioned in this thread (just a med student here).

 

[deleted875186]

Tough case. Would definitely slow down, make sure he is resuscitated (to the question above, HR is reasonable, would give volume and blood based off rough estimate of how much he lost in the field if you got a report and BP), bring to OR with ENT ready for trach. Have a good look in the mouth to assess, could even use the fiberoptic with ENT to take a good survey.

1. the AFOI described above is excellent if able to do it. Would sedate with fentanyl or Remi titrated to effect, and and a small dose of hypnotic or ketamine.

2. if able to keep pressure on the vessel and still access the mouth, can try DL and RSI, ENT prepped and ready for trach. I too am worried that patient will not be baggable if intubation fails, will aspirate a bunch of blood, and your only way to ventilate will be and LMA. I would induce with prop, hypotension will be tolerated if resuscitated and will help your view

3. board answer is awake trach however ENT decides to open or perc with local and sedation, probably the safest in my opinion. Patient will be rapidly decannulated so it’s not a huge deal.

4. Plan 4 is awake ECMO lines .... jk

 

[Beeftenderloin]

What is the difference in indication between a cric and an awake trach in this situation? I know the anatomy difference but just wondering why both have been mentioned in this thread (just a med student here).

Mostly comes down to provider comfort. ENT is more likely to do a trach in an emergency because they do a lot of them, are comfortable with the procedure, and can do it quickly. But at my shop, in the middle of the night, surgical airway back-up is trauma. If they’re cutting the neck in an emergency it’s going to be a cric now, establish airway, trach once airway is secure. Cric is an easier, landmark based technique for people who don’t operate on that real-estate with frequency.

Main difference between the 2 is that a cric is a temporary solution. They’ll need a formal trach eventually.

 

[coffeebythelake]

Mostly comes down to provider comfort. ENT is more likely to do a trach in an emergency because they do a lot of them, are comfortable with the procedure, and can do it quickly. But at my shop, in the middle of the night, surgical airway back-up is trauma. If they’re cutting the neck in an emergency it’s going to be a cric now, establish airway, trach once airway is secure. Cric is an easier, landmark based technique for people who don’t operate on that real-estate with frequency.

Main difference between the 2 is that a cric is a temporary solution. They’ll need a formal trach eventually.

I would feel comfortable doing a needle cric myself. We do them in the cadaver lab and it isn't that complicated.

 

[Hork Bajir]

ECMO all day baby! When you’re a hammer, everything starts to look like a nail...

 

[IlDestriero]

Uhhhh....all do respect, this is why I get worried when we get a rotating anesthesiologist - having someone who first trauma primarily is great, having someone who still considers themself the end-all be all airway expert while only doing total hips.....

If you have a bleeding trauma patient with a HR>120, I would not consider that patient hemodynamically stable.

Well if you have a relatively stable trauma patient that you believe is hemodynamically unstable and RSI them without further attempts at resuscitation, it doesn’t matter if you’re the airway king or not. I’m happy to just be a Prince. But the ER and the ICU defer to the Princes when they get difficult airways. Not sure why?
#LongLiveTheKing

 

[deleted547339]

Well if you have a relatively stable trauma patient that you believe is hemodynamically unstable and RSI them without further attempts at resuscitation, it doesn’t matter if you’re the airway king or not. I’m happy to just be a Prince. But the ER and the ICU defer to the Princes when they get difficult airways. Not sure why?
#LongLiveTheKing

I would have no problem with the patient going to the OR with anesthesia and ENT or trauma. Very reasonable answer. There’s a lot of reasonable choices here. I just think the “step aside lowly ER doc” attitude doesn’t help anyone.

 

[deleted547339]

How would you plan to instrument the airway if he’s not sedated? Would you do the blocks or some other technique?

I also would not want to lean him back to look with a VL... the trickle of blood coming out of the mouth would quickly become a puddle around the glottis if he were supine.

Maybe you could try VL with him upright, but I’ve never tried that before.

Do it all the time. Works really well if the patient is cooperative. We usually do it to drain PTAs. Do it similar to an awake FOI after nebs +/- topical. When patients hold the VL, they can go a lot deeper than you’d think. I’ve also done it on patients with trismus. It’s gives you a free look to know “ok, chip shot, fine to go.”

 

[alpinism]

Sounds like a fairly straightforward small caliber facial gunshot wound with associated oropharyngeal bleeding.

Not really a big deal just suction the arterial bleeder with a large bore catheter while you perform direct laryngoscopy.

We'll usually have at least one a week and there's no reason to go straight to backup or surgical airways in my experience.

 

[freedeshaun2021]

Do it all the time. Works really well if the patient is cooperative. We usually do it to drain PTAs. Do it similar to an awake FOI after nebs +/- topical. When patients hold the VL, they can go a lot deeper than you’d think. I’ve also done it on patients with trismus. It’s gives you a free look to know “ok, chip shot, fine to go.”

Interesting-- I wouldn't have thought that the nebs/topical lidocaine would work if there was blood in the field.

Some of my co-residents suggested doing a VL with him sitting up and holding the blade upside down-- I may have been able to do that and used the fiber as a driveable stylet.