Another Boring Airway Case

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Noyac

Noyac

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I know we discuss a lot of airway cases but this one I had last night taught me something.

32 yo male states he took some Benadryl for a swollen tongue then passed out and was found by him friend bleeding profusely from the mouth. EMS transferring him to us from outside hospital for airway management and repair of huge tongue laceration. I see him on arrival in ER and his tongue protruding out of his mouth and there is a large stellate laceration on the underside of his tongue. Pt is leaning forward and has yankuer in his hand which is full of blood. On exam his tongue has complete occluded his mouth and he can only breath through his nose. Short stocky neck, not overly obese. Pt can't close his mouth at all. Tongue is extremely painful, hard and swollen.

PMH:
MI at age 26
Mom reports past Sz but pt denies this.
No meds
No allergies

Plan?
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Retrograde wire, prop sux tube?

Will let the residents chime in first.

MI@ 26, WTF?
 
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Assuming he's stable, then temporize while getting resources together. Stop the bleeding. Put a wad of 4x4's under his tongue to stem the blood flow, maybe soak them in bupivicaine w/ epi to vasoconstric and give a little pain relief. Is he on Plavix or ASA or both for stents after the MI. Fix the coags before he bleeds to death. Some other anticoagulant that cannot be reversed? Move him to the OR with two portable suctions, get an otolaryngologist to place silver nitrate sticks or maybe throw an awake stitch or 5 in the tongue. 10 of decadron to temper the swelling, and consider why his tongue was swelling in the first that made him reach for the benadryl bottle. Anaphylaxis/toid rxn that is going to get worse? If the bleeding slows, and the tongue is not growing maybe give racemic epi to further minimize the swelling of the tongue. Bleeding stops/slows enough, and there's room in the mouth, then consider a glidescope, or an awake (or asleep w/ spontaneous respirations) FOB after topicalization assuming trace bleeding at worse. On anticoagulants? Avoid nasal FOB. If he crashes, or loses his airway before the bleeding stop, surgical airway with a Melker if placed by me, a blue rhino percutaneous trach if placed by the ENT docs.
 
gtb said:
Assuming he's stable, then temporize while getting resources together. Stop the bleeding. Put a wad of 4x4's under his tongue to stem the blood flow, maybe soak them in bupivicaine w/ epi to vasoconstric and give a little pain relief. Is he on Plavix or ASA or both for stents after the MI. Fix the coags before he bleeds to death. Some other anticoagulant that cannot be reversed? Move him to the OR with two portable suctions, get an otolaryngologist to place silver nitrate sticks or maybe throw an awake stitch or 5 in the tongue. 10 of decadron to temper the swelling, and consider why his tongue was swelling in the first that made him reach for the benadryl bottle. Anaphylaxis/toid rxn that is going to get worse? If the bleeding slows, and the tongue is not growing maybe give racemic epi to further minimize the swelling of the tongue. Bleeding stops/slows enough, and there's room in the mouth, then consider a glidescope, or an awake (or asleep w/ spontaneous respirations) FOB after topicalization assuming trace bleeding at worse. On anticoagulants? Avoid nasal FOB. If he crashes, or loses his airway before the bleeding stop, surgical airway with a Melker if placed by me, a blue rhino percutaneous trach if placed by the ENT docs.
Click to expand...


To OR for Trach by ENT.
 
I'm debating awake trach vs nasal fiberoptic. If he can phonate I'll try fob without any sedation while he sits leaning forward. Spray local via scope as you go.
 
Noyac said:
No ENT available.
Click to expand...

Does the hospital have ENTs on call? Or are they unavailable at the moment?

Thoracic surgeon? Trauma surgeon? General surgeon with experience?

Regardless of what you choose, you need instruments and a surgeon to manage this airway, either as primary or back-up.

Probably a quality control issue. Every hospital should have a surgeon capable of performing an emergent Trach.
 
urge said:
The ER should have never accepted the patient. Some heads need to roll.
Click to expand...

+1

Inexcusable to have a patient with an airway like that an no one available for a Trach.
 
Awake nasal fiberoptic intubation or at least bougie placement.
 
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IlDestriero said:
Anesthesiologists can do a surgical airway.
Click to expand...
I don't know any anesthesiologist credentialed to do trachs.

That being said, give me a cafeteria knife and I will manage.
 
Secure his airway while he is awake whichever way you like. Protect his airway post op until the swelling subsides whether its post op day 1 or 5. i think inducing this guy is asking for problems. Any hospital should have ENT available. Perhaps the hospital did not want to pay the call subsidy.
 
I really hate to put anything in the nose if the mouth is so messed up. So... at this point all I can do is look in the mouth using as much topical anesthesia as I could... maybe with a transtracheal block too, I might use some video scope or fibereoptic with lots of suction but if I can't see anything I would stop and still avoid touching the nose, and work on aranging for a surgical airway.
 
criticalelement said:
Secure his airway while he is awake whichever way you like. Protect his airway post op until the swelling subsides whether its post op day 1 or 5. i think inducing this guy is asking for problems. Any hospital should have ENT available. Perhaps the hospital did not want to pay the call subsidy.
Click to expand...
Every hospital most certainly doesn't have ENT available. Little community hospitals have an ED and only a general surgeon on call. When he's 45 min away at dinner, it's you, the ED guy (who might be an FP), or the morgue.
 
IlDestriero said:
Every hospital most certainly doesn't have ENT available. Little community hospitals have an ED and only a general surgeon on call. When he's 45 min away at dinner, it's you, the ED guy (who might be an FP), or the morgue.
Click to expand...
That's fine. But, I don't think they should be accepting ENT patients.

Who is going to trach and suture this tongue? The FP guy?

Might as well tell the ambulance to go to the next hospital with ENT services.
 
IlDestriero said:
Every hospital most certainly doesn't have ENT available. Little community hospitals have an ED and only a general surgeon on call. When he's 45 min away at dinner, it's you, the ED guy (who might be an FP), or the morgue.
Click to expand...

It's inappropriate to be on call and 45 minutes from the hospital. In our group policies, I am to respond within 30 minutes.

This isn't a situation like the oral board where you are in a very bad situation that can happen in delivering a standard of care. IMHO, not having surgical expertise within a reasonable distance/time to the ER in a difficult airway to provide back-up or just straight up awake trach the guy is a violation in the standard of care.

If in this situation, I would have a crich kit on hand and communicate to all parties involved that this is a life-threatening situation and we need a surgeon there STAT. Unless this patient is crumping, I am waiting for a surgeon with trach capabilities and not giving any sedation or poking him with any needles.
 
urge said:
The ER should have never accepted the patient. Some heads need to roll.
Click to expand...
Coming from outside hospital, they don't give good report. This is either because they want to get rid of the pt or they didn't really look at the pt. Nevertheless, they don't need to be handling these pts. We will take them every time.
 
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Ok good comments so far. We have one ENT at our hospital. He is on call 14 days a month. Nobody can be on call every day.
This case was accepted by our oral maxillofacial guy. Now it's my issue.
We have some gen/trauma surgeons that can teach a pt.
Pt was not crumping. YET!
 
I think out specialists have a one hour window on call. Except for the trauma team. (General and neuro). All the attendings take home call and most live in suburbia.
If you're not a trauma center, it might take a lot longer than an hour to get someone in to see the patient.
 
Ignatius J said:
It's inappropriate to be on call and 45 minutes from the hospital. In our group policies, I am to respond within 30 minutes.

If in this situation, I would have a crich kit on hand and communicate to all parties involved that this is a life-threatening situation and we need a surgeon there STAT. Unless this patient is crumping, I am waiting for a surgeon with trach capabilities and not giving any sedation or poking him with any needles.
Click to expand...
You have wisdom beyond your years. I didn't start thinking this way until i was 3 years post residency. This case has medico-legal written all over it. You have to think in a clear manner.
 
Things are always fluid depending on what i see at bedside. The internet is hard to represent that aspect of the case. Here is how I aproach it:

What does he LOOK LIKE and what are his SATS and RR? Is he chill or about to decompensate? That is my first question on this case.

My second quesiton is:
Do you think you can get a nasal ETT easily passed?

Along with...
Is the patient in acute jepordy?
Getting worse?
How much time do I think I really have?
Could a nasal FO make things worse?

If the answer to the above is yes or possibly + No ENT or provider that can do the job then ----> AWAKE CRIC. You need to ball up unless there is another experienced provider.

On the other hand... If you have time, then the rest can wait until you can get a provider that can handle this thick neck.

What you can't do... is get behind the 8 ball and then wish you had done something.

This is a good exercise NOY... I've been here before and these are the questions that have gone through my head.

Not a boring case.... my wife just went through this... except she had a decompensating patient from the get go... I'll give you the details later but she was the smartest person in the room (ent present) and rocked it.

Knew HOW to save the patients life... 100%.
 
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Noyac said:
I know we discuss a lot of airway cases but this one I had last night taught me something.

32 yo male states he took some Benadryl for a swollen tongue then passed out and was found by him friend bleeding profusely from the mouth. EMS transferring him to us from outside hospital for airway management and repair of huge tongue laceration. I see him on arrival in ER and his tongue protruding out of his mouth and there is a large stellate laceration on the underside of his tongue. Pt is leaning forward and has yankuer in his hand which is full of blood. On exam his tongue has complete occluded his mouth and he can only breath through his nose. Short stocky neck, not overly obese. Pt can't close his mouth at all. Tongue is extremely painful, hard and swollen.

PMH:
MI at age 26
Mom reports past Sz but pt denies this.
No meds
No allergies

Plan?
Click to expand...

DUDE IS CONSCIOUS AND BREATHING.
Hit him with methylprednisilone 125mg STAT.
Epi .5mg subcu too.
You may actually be able to handle this in the ER without going to the OR, which SHOULD BE your ULTIMATE GOAL...to NOT put this dude to sleep...because THIS is the case that we all read about in the I'M GLAD I WASN'T THERE journal reports.
If it starts going bad,
DUDE. I'M A COWBOY BUT I'M TAKING THIS S H IT SERIOUSLY.
This is not a Cowboy Case.
I'm calling out an ENT HOMIE to be there on induction.
If this case requires surgical intervention, induction of anesthesia could
GO SOUTH. CDAZY FAST.
I'd have the dude's cricothyroid membrane marked with a Sharpie.
And I'd have my ENT Buddy standing next to me.
Hoping you didn't have to put this dude to sleep...yeah we are ROKKSTARRS and we have all these tricks up our sleeves....(Glidescope, etc)....but
THIS SHI T'S FOR REAL MAN.
This is NOT a Cowboy Case.
Try and deal with it in the Emergency Room. Under Local. With the patient breathing. If that's not possible,
SEND OUT ALL ALERTS.
 
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I would first get a cric kit ready and do the local anesthesia beforehand.
Bloc one nare and see if he can breath/maintain sats with one one nare open (that's what's going to happen when you put a scope/tube down his nose).
If he can, topicalize nare with epi, trans tracheal block then leave a 14g angiocath in the trachea and try fiberoptic intubation, if not strait to awake cric.

I would not induce the patient unless ENT is present and ready to slash the neck
 
Any previous history of mouth/tongue swelling? Any family history? Abx? ACEI's? Gotta go through the nose here awake, probab no room to put anything in the mouth. Localize as per routine (i love transtracheals), precedex, maybe a little ketamine/versed, suction really good, have someone hold some suction up top, maybe use some gauze to try to stop bleeding during FOI, hopefully with an underside of tongue lac, you can keep the blood out of the pharynx
 
Alright we are off and running with is case. So I think we all agree that we are not going to induce this guy. Good call.
I went I to the hospital thinking it was not going to be a big deal. Well I was woefully mistaken. We're I screwed up was that I didn't call my ENT buddy or the trauma surgeon right away. Maxillofacial guy wanted to take care of this in the ER until we saw the pt and then we both said no way. To the or.

Let's talk about how we are going to topicalize him first since my ******* didn't call a surgeon in.

I will also say this, originally there was no way I was gonna sedate this guy whatsoever. No precedex, no versed nothing. But then I decided to give 1mg of versed to see what happened and because I'm thinking it was a seizure and if he seizes again we're screwed. I'll stop there.
 
FFP said:
Awake nasal fiberoptic intubation or at least bougie placement.
Click to expand...

1.) Still wondering why he's bleeding like a stuck pig long after biting his tongue. And, I'm wondering how to keep my FOB lens from smearing with blood and clot that's going to make it useless. He denies meds, what about weird foods, supplements, or ASA that he might have loaded up on for a painful back? If direct pressure and packing can't stop the bleeding enough to tropicalize the airway, a successful awake FOB seems like wishful thinking. Even with phenylephrine or oxymetazalone in the nose, if he has some problem with coagulation (vWF deficiency, hemophilia, etc.) the nasal FOB might worsen the blood in the airway. If there's time for coags, then do it before nasal FOB, fix what you can, then

2.) Still wondering why he reached for the Benadryl as his tongue started to swell immediately before losing consciousness. He says no allergies, but any food allergies. Did he eat a peanut coated chocolate banana knowing he's got a mild peanut allergy? Ii sounds like he knew that Benadryl would help anytime his tongue swelled up. Do I need to get prepared for an incredibly worsening upper airway disaster because he is continuing to swell? If he nods his head yes to anaphylaxis as a possibility, treat that in addition to the other problem of a bloody airway - and think more about a quick surgical airway if he completely obstructs.

3.) Why did he lose consciousness and bite his tongue. Did the ED think seizure as a possibility? Did they give him Keppra or another anti seizure med to lower the risk of another seizure occurring (if that was the LOC etiology)? Another seizure is really going to complicate things with a mouth full of blood.

4.) I completely, totally, absolutely believe an ENT isn't available. Just the way it is out in the bad old world. If he was stable when the EMS transferred him to you, maybe you can transfer him back to the originating OSH? Or maybe to a nearby hospital that has otolaryngology actually in house? Probably not an option.

So, you're left with a bloody airway, still actively bleeding, a swollen tongue that might or might not be worsening, a man with a cardiac history, maybe ongoing anaphylaxis / anaphylactoid rxn, and maybe a seizure leading to lost consciousness and biting of his tongue. Oh, and no ENT surgeon immediately available.

Keep the patient calm; don't let him panic more by openly displaying your own fears. A nice calm voice while you talk to everyone. It's not you with the impending loss of the airway. Call the techs (if you're so lucky) to set up the OR with all the difficult airway tools, and make sure the OR knows your coming and staffs the room with surgical nurses, scrub techs, and sets up for a trach. Make sure some type of surgeon knows you'd really love some help in the OR. Stick some gauze soaked in phenylephrine or epi under the tongue to try to slow the bleeding. Treat any possible allergic rxn. Also, give him some glycopyrolate before moving to do what you can to dry things up before moving. 100% O2 nonrebreather to oxygenate as much as you can just in case he completely obstructs. Don't let him lose spontaneous ventilation by over medicating. Move to OR w/ portable suction & him stilling up in the bed and you by the bedside. Melker with you doing transport (). What's next depends on how things are going when you get to the OR. If there's time to wait then stop the bleeding first, fix any other problems (coags, anaphylaxis, seizure d/o, etc.). If things are getting better, the tongue swelling is resolving, the bleeding is only a trickle, no likelihood of recurrent seizure, consider doing nothing. Otherwise, tropicalize, and proceed with an awake FOB intubation if he'll cooperate. Otherwise, if things are going bad, move on with awake trach if the patient can cooperate.

As long as you can get access to the cricothyroid membrane, you have a fallback emergency plan for a quick surgical airway. If you can't palpate the CTM, use ultrasound to locate and mark it - plenty of manuscripts on that topic - do an emergency surgical airway once he loses consciousness.
 
urge said:
I don't know any anesthesiologist credentialed to do trachs.
Click to expand...

Individual hospitals are the credentialing authority for each physician that practices there. At Swedish in Seattle, once you do 10 proctored percutaneous tracheostomies, you can apply for credentials for this procedure. The anesthesia critical care docs are likely credentialed for this.
 
Noyac said:
Alright we are off and running with is case. So I think we all agree that we are not going to induce this guy. Good call.
I went I to the hospital thinking it was not going to be a big deal. Well I was woefully mistaken. We're I screwed up was that I didn't call my ENT buddy or the trauma surgeon right away. Maxillofacial guy wanted to take care of this in the ER until we saw the pt and then we both said no way. To the or.

Let's talk about how we are going to topicalize him first since my ******* didn't call a surgeon in.

I will also say this, originally there was no way I was gonna sedate this guy whatsoever. No precedex, no versed nothing. But then I decided to give 1mg of versed to see what happened and because I'm thinking it was a seizure and if he seizes again we're screwed. I'll stop there.
Click to expand...


Does your OMFS guy do trachs? The ones we have that do big face cases will. With the right topicalization, you just don't have to have sedation for a FOI. That being said, I just haven't seen anybody obstruct with precedex. I work in a place where we do a whole lot of head and neck cancer stuff and do a lot of awakes. I use it for most of my FOI's. Even pt's with pretty bad supraglottic pathology don't obstruct with precedex alone. It's especially great for planned "awake trachs". We do a fair number of those too. I usually do a .5-1 mcg/kg bolus on a pump over 10 minutes and thats usually about all I need. They don't obstruct, most of the time sats will maintain (even on room air), pt's are reasonably cooperative.
 
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Noyac said:
I will also say this, originally there was no way I was gonna sedate this guy whatsoever. No precedex, no versed nothing. But then I decided to give 1mg of versed to see what happened and because I'm thinking it was a seizure and if he seizes again we're screwed. I'll stop there.
Click to expand...

I don't like playing with fire. Why not give him an anti seizure medication? Dilantin, keppra?
 
pd4emergence said:
Does your OMFS guy do trachs? The ones we have that do big face cases will. With the right topicalization, you just don't have to have sedation for a FOI. That being said, I just haven't seen anybody obstruct with precedex. I work in a place where we do a whole lot of head and neck cancer stuff and do a lot of awakes. I use it for most of my FOI's. Even pt's with pretty bad supraglottic pathology don't obstruct with precedex alone. It's especially great for planned "awake trachs". We do a fair number of those too. I usually do a .5-1 mcg/kg bolus on a pump over 10 minutes and thats usually about all I need. They don't obstruct, most of the time sats will maintain (even on room air), pt's are reasonably cooperative.
Click to expand...
I will agree that precedex can be a good addition to an awake FOI in a calm pt. I have not been impressed with it in the acutely agitated afraid for their life type pts.

Yes the OMF guy has done a trach or two. I also had the cric kit out and ready.
 
In order to move this case along, here is what I planned.
Awake FOI via the right mare after some solid topicalization. I like viscous lido but this guy couldn't do that since there was no room in his mouth for the lido so I went with plan B there, lido neb after some glyco IV. LUckily his airway wasn't deteriorating. I had some time. Next I would topicalize his nose with Afrin and lidocaine lubed nasal trumpets until I got him dilated enough. Then I would proceed with a transtracheal injection.

Thoughts?
 
The problem with inserting things in the nose in this patient is that if you cause a nose bleed you have a very serious problem and the breathing could become quickly compromised.
If my plan was a nasal intubation I would not proceed without having someone with the skill and equipment ready for immediate cricothyroidotomy.
 
Any body using this thing? Ive recently started using it and have pretty good results. I usually put a bend like shown, go through the nose and have the patient take a breath.

mad.jpeg
 
Planktonmd said:
The problem with inserting things in the nose in this patient is that if you cause a nose bleed you have a very serious problem and the breathing could become quickly compromised.
If my plan was a nasal intubation I would not proceed without having someone with the skill and equipment ready for immediate cricothyroidotomy.
Click to expand...
I somewhat agree. Yes if you stir up significant bleeding then you may have screwed yourself. However, in my hers of doing this I have never had this happen. Therefore, I go with what I have done in the past with success.

Also, this guy has enough blood in hi airway that I doubt I can make it worse. But then again, I guess things can always get worse, right.
 
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Noyac said:
I somewhat agree. Yes if you stir up significant bleeding then you may have screwed yourself. However, in my hers of doing this I have never had this happen. Therefore, I go with what I have done in the past with success.
Click to expand...
But this guy is only still breathing because the nose and the nasopharynx are still patent, if we fill them with blood it's game over!
 
Something I would do here as I got ready for the nasal fiber: take a nasal trumpet, cut it lengthwise. After some neo spray/ lido grease on the trumpet, insert it in one of the nares.

This will serve two purposes: 1) any bleeding you may otherwise have stirred up should be tamponaded, and 2) you now have a nice atraumatic conduit for your FOI that will accommodate an ETT (I.e. with the slit cut into it you can fit whatever down it.
 
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I agree that if we "fill" them with blood it would be game over but when have you seen a nose bleed so bad that the pt couldn't breath? Even the worst nose bleed will allow time to cric a pt. And if the bleed is bad just put a trumpet in it and now they breath past it. I have only seen bad nose bleeds after SMR surgery. Actually had one 3weeks ago and the guy was sitting forward spitting blood out of his mouth in large quantities. Hct dropped 7 pts which is significant. But he could still breath through his nose. His problem was uncontrolled HTN post op and once the epi wore off and the vasoconstriction was gone, he started pumping out blood. That was an easy airway compared to this one. Slam dunk.
 
Hawaiian Bruin said:
Something I would do here as I got ready for the nasal fiber: take a nasal trumpet, cut it lengthwise. After some neo spray/ lido grease on the trumpet, insert it in one of the nares.

This will serve two purposes: 1) any bleeding you may otherwise have stirred up should be tamponaded, and 2) you now have a nice atraumatic conduit for your FOI that will accommodate an ETT (I.e. with the slit cut into it you can fit whatever down it.
Click to expand...
This is an I teresting approach. I've never done this.

But since we are moving along in this case, I did this minus cutting it length wise. But this is when I really started to notice how bad things were. I could only insert the trumpet thru the nose. Once the tip started to enter the oropharyngeal cavity I met resistance. Now what? Besides the obvious, awake trach.
 
I would stop ... Take a breath, suction, and figure out the best way to get a surgical airway in this patient with whatever resources I have available.
If I am it and there is no one else I would proceed with an awake per cutaneous cricothyrodotomy
 
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Planktonmd said:
I would stop ... Take a breath, suction, and figure out the best way to get a surgical airway in this patient with whatever resources I have available.
If I am it and there is no one else I would proceed with an awake per cutaneous cricothyrodotomy
Click to expand...

Do you have a particular kit available or would you cobble together supplies?
 
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