Another Boring Airway Case

[deleted547339]

ER Resident chiming in:

If this happens at The Mecca --> to OR with ENT

If this happens at the community hospital --> trauma surgery bedside vs. OR cric/trach in resus bay

If this happens to me at a tiny moonlighting hospital, I'd call for any help possible - surgery, ENT, anesthesia, whoever. I'd give some benadryl, h2 blocker, steroids and FFP yesterday. I'd have a 100% non-rebreather on him. His neck would be prepped and numbed already. I'd have ketamine at bedside. I'd wait, with scalpel and bougie in hand, to see if any of the meds or FFP would work.

This is what Richard Levitan calls the "Inevitable surgical airway." There's no way plastic is getting through this guys cords, short of a miracle. I don't see a nasal airway passing. I don't see how a retrograde wire would help. If I don't have backup, I'm it. If I have surgical backup, I wait at bedside. If this guy so much as looks at me funny, I'm cutting. Otherwise, I wait. If I didn't have surgical backup, I would proceed with a surgical airway. I'd go cric with bougie. I don't see how this could proceed any other way successfully.

In no way, shape or form am I transporting this guy without plastic in his trachea. Letting this guy leave my sight without a definitive airway isn't going to happen.

Ya'll may disagree, but that's what I would do. Then I would change my pants...

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[Noyac]

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

We have two different kits. Not sure the names of them. I'd have to look again. I don't use them often, more like never.

 

[Arch Guillotti]

We have two different kits. Not sure the names of them. I'd have to look again. I don't use them often, more like never.

It is easy to say you would crich a pt. in extremis but my reality is that you can't do it without proper supplies. When a pt. is dying or actively losing their airway in front of you in the ED it isn't always easy to have someone run get the exact supplies that you may need. You may have to improvise in a dire situation. I haven't ever done it (nor do I really have the desire to) but one of these days I can see myself doing an emergency airway with a central line kit from the ED.

 

[Noyac]

ER Resident chiming in:

If this happens at The Mecca --> to OR with ENT

If this happens at the community hospital --> trauma surgery bedside vs. OR cric/trach in resus bay

If this happens to me at a tiny moonlighting hospital, I'd call for any help possible - surgery, ENT, anesthesia, whoever. I'd give some benadryl, h2 blocker, steroids and FFP yesterday. I'd have a 100% non-rebreather on him. His neck would be prepped and numbed already. I'd have ketamine at bedside. I'd wait, with scalpel and bougie in hand, to see if any of the meds or FFP would work.

This is what Richard Levitan calls the "Inevitable surgical airway." There's no way plastic is getting through this guys cords, short of a miracle. I don't see a nasal airway passing. I don't see how a retrograde wire would help. If I don't have backup, I'm it. If I have surgical backup, I wait at bedside. If this guy so much as looks at me funny, I'm cutting. Otherwise, I wait. If I didn't have surgical backup, I would proceed with a surgical airway. I'd go cric with bougie. I don't see how this could proceed any other way successfully.

In no way, shape or form am I transporting this guy without plastic in his trachea. Letting this guy leave my sight without a definitive airway isn't going to happen.

Ya'll may disagree, but that's what I would do. Then I would change my pants...

This is a good post, for an ER doc. Ha ha.
A couple things I like in this post are, don't send this guy elsewhere. Retrograde wire is unlikely to work. Wait for surgical help if possible.

 

[Noyac]

So what do you guys/gals think happened when I tried to topicalize this guy? This was my big learning moment in this case.

 

[Planktonmd]

So what do you guys/gals think happened when I tried to topicalize this guy? This was my big learning moment in this case.

He started bleeding from the nose and possibly vomiting?

 

[deleted171991]

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.

Put in a well-lubricated pedi FO scope, take a look. If ugly, awake surgical airway under local.

 

[deleted171991]

So what do you guys/gals think happened when I tried to topicalize this guy? This was my big learning moment in this case.

Did he start bleeding from the lidocaine? The Afrin/phenylephrine should have prevented that.

I wouldn't rule out vomiting, like planktonmd said, given how much blood this guy must have ingested by now.

Don't tell me he went into anaphylaxis or a seizure.

 

[BLADEMDA]

Noyac,

I've had 3 of these cases during my career. Two of them nearly died. One was a brief code while the surgeon did the cric. That guy lived to leave the hospital.


Bottom line is if you sedate this guy with only a Glidescope available you are rolling the dice. Never be afraid of calling for backup before you start the awake FOI. During my career I've called for backup just 4 times and all those patients survived.

 

[pd4emergence]

So what do you guys/gals think happened when I tried to topicalize this guy? This was my big learning moment in this case.

I've found that when the supraglottic pathology is obstructive enough, its really hard to get them numb.....

 

[BLADEMDA]

I've found that when the supraglottic pathology is obstructive enough, its really hard to get them numb.....

What matters is whether you can see the cords. If you can visualize the cords with the FO scope then your assistant ( you need at least 1 if not 2) can gently add sedation just before you put the plastic through the cords.

The key here is not to get in over your head with sedation followed by a poor view of the Glottic opening. I can tell you from experience this may result in a stat cric instead of an emergent cric.

 

[IlDestriero]

So what do you guys/gals think happened when I tried to topicalize this guy? This was my big learning moment in this case.

Gagging,vomiting, emergent surgical airway.

 

[BLADEMDA]

In my of my close to death airway disasters I got the FO scope right above the cords. I thought this is easy street now. But, as I got closer and closer to the cords I noticed edema around the glottic opening. So, I had to decide whether to stop with the FOI or power through through the edema. Since my failing to get the FOI meant the patient needed a cric I decided to power through the slightly edematous Glottic opening. The result was I couldn't pass the ETT, the patient went into Laryngospasm and I had a huge mess on my hands. Now, I had an emergent cric/trach and an impeding full code.

 

[IlDestriero]

In my of my close to death airway disasters I got the FO scope right above the cords. I thought this is easy street now. But, as I got closer and closer to the cords I noticed edema around the glottic opening. So, I had to decide whether to stop with the FOI or power through through the edema. Since my failing to get the FOI meant the patient needed a cric I decided to power through the slightly edematous Glottic opening. The result was I couldn't pass the ETT, the patient went into Laryngospasm and I had a huge mess on my hands. Now, I had an emergent cric/trach and an impeding full code.

That's a good lesson. Upper airway edema might also be tracheal and glottic edema and seeing the cords doesn't mean you can get a tube in.
Some cases need a surgical airway and there's no getting around it.
We have the flexible tip tubes for our fiberoptic intubations, to help it not get caught. I can't remember the name. I think they're Parker.

 

[deleted171991]

That's a good lesson. Upper airway edema might also be tracheal and glottic edema and seeing the cords doesn't mean you can get a tube in.
Some cases need a surgical airway and there's no getting around it.
We have the flexible tip tubes for our fiberoptic intubations, to help it not get caught. I can't remember the name. I think they're Parker.

How much does it help to rotate the tube 90 degrees?

 

[Planktonmd]

That's a good lesson. Upper airway edema might also be tracheal and glottic edema and seeing the cords doesn't mean you can get a tube in.
Some cases need a surgical airway and there's no getting around it.
We have the flexible tip tubes for our fiberoptic intubations, to help it not get caught. I can't remember the name. I think they're Parker.

To minimize the chances of the tube getting stuck on the cords use a tube that fits snugly on the scope,
The less difference in diameter there is between the scope and the tube the less likely the tube would get stuck.

 

[Noyac]

Awesome discussion.
So what I learned is that you can't topicalize well an airway when blood is coating all the mucous membranes. I tried to use nebulizded lido via the nose. It didn't work well. You may want to try injections but in this case I couldn't inject the glossopharyngeal nerves. I could have injected the greater Cornu of the hyoid but I was definitely doing a transtracheal so that I knew were to go if I need to cric. But sense he had aspirated so much blood during the coarse of events leading up to the OR, my transtracheal lido was ineffective mostly. Luckily it did splash up on the cords though and prevented laryngospasm.

Next, I started to progressively dilate and topicalize the right nare since the majority of the swelling was in the left side of the mouth but that didn't mean the the right side wasn't nearly obstructed as well. I passed the first small nasal trumpet and it slide pretty easily thru the nose but met significant resistance just beyond the soft palate. It was the tongue. I thought is was screwed. The trumpet was still sticking out of the nose about 2". I didn't stri up any more bleeding so I slowly gently continued. The pt was very uncomfortable when the trumpets would hit the tongue. The tongue was so swollen and tight that any pressure on it was excruciating to him. But I got the nose dilated and somewhat numb. So I decided to load a nasal Rae the on my pediatric scope and see if I could wiggle around the side of the tongue. For those of you new to nasal intubations, the best thing about it is that as you pass the tube thru the nose it is the most direct approach to the cords. Much better than the oral approach. Now by having to wiggle laterally around the tongue I have just lost this advantage. Obviously I couldn't see where I was going but to my amazement it worked and the guy was able to tolerate it somewhat. Now I had to find the cords. There was so much blood back there that I nearly pulled out and abandoned everything. The pt wasn't in distress respiratory wise and I hadn't burned any bridges. Plan B was call in people in the middle of the night and we do an awake trach.

As I was in there I proceeded to look around a bit and through all the blood splashing around I was pretty sure I saw where the bubbles were coming from. So I pulled the scope out and cleaned out the blood. Passed some suction down the ETT and tried to clear out as much as possible. I went in one more time and saw the bubbles again. Shot the gap and wala lucky MF'r.

Usually the awake FOI is smooth when well topicalized but this was not the case. He was poorly topicalized and struggling but cooperative the entire time. When I passed thru the cords he started to cough and blood started coming up the ETT. It was a smaller size tube and he could vocalize around it. I was like WTF is going on now. He was not reaching for the tubes s things were ok but I didn't want to paralyze him at all so I turned on the gas and gave a small dose of propofol. Somewhat worried that he tube may have dislodged but I had ETCO2. So I was a thinking I may be just above the cords. As I inflated th cuff he began to cough more. This told me I was probably in the trachea but not 100% sure. I could bag him and there wasn't much of a leak at all so I took the leap of faith and continued to sedate more but slowly in hopes that I could recover if not in. I was definitely taking a chance. He was starting to settle down and I was still getting good ETCO2 and was able to add more air to the cuff. Things were looking good. I went back down with the scope but couldn't see shat due to all the blood in the trachea. So I came out and passed a suction cath. The pt was asleep now and spontaneously breathing well. All was good. Wow what a **** show. Hands down worst airway I have ever seen. Funny thing is that the report from outside hospital was nothing like what we ran into. The ER didn't appreciate the situation either. OMF guy said "I wasn't worried, I knew you would get it".

Follow up, the ICU guy didn't want him to come their way unless he was trach'd. I said, I'm not calling in someone at midnight to trach a secured airway. So we sewed the tube in twice and restrained his arms over night. He got trach'd the next day since we could wake him up with a trach but not with out a tube since the swelling was still quite bad. In my opinion, this guy was going to be a very difficult awake trach at the moment. This ended up being the best of all outcomes. I don't think he would have held still and we would have had to trach him in the sitting position. It would have sucked. Therefore, I felt that this was our best approach. Thank god it worked.

 

[deleted171991]

What will you do differently next time?

 

[nap$ter]

Awesome discussion.
So what I learned is that you can't topicalize well an airway when blood is coating all the mucous membranes. I tried to use nebulizded lido via the nose. It didn't work well. You may want to try injections but in this case I couldn't inject the glossopharyngeal nerves. I could have injected the greater Cornu of the hyoid but I was definitely doing a transtracheal so that I knew were to go if I need to cric. But sense he had aspirated so much blood during the coarse of events leading up to the OR, my transtracheal lido was ineffective mostly. Luckily it did splash up on the cords though and prevented laryngospasm.

Next, I started to progressively dilate and topicalize the right nare since the majority of the swelling was in the left side of the mouth but that didn't mean the the right side wasn't nearly obstructed as well. I passed the first small nasal trumpet and it slide pretty easily thru the nose but met significant resistance just beyond the soft palate. It was the tongue. I thought is was screwed. The trumpet was still sticking out of the nose about 2". I didn't stri up any more bleeding so I slowly gently continued. The pt was very uncomfortable when the trumpets would hit the tongue. The tongue was so swollen and tight that any pressure on it was excruciating to him. But I got the nose dilated and somewhat numb. So I decided to load a nasal Rae the on my pediatric scope and see if I could wiggle around the side of the tongue. For those of you new to nasal intubations, the best thing about it is that as you pass the tube thru the nose it is the most direct approach to the cords. Much better than the oral approach. Now by having to wiggle laterally around the tongue I have just lost this advantage. Obviously I couldn't see where I was going but to my amazement it worked and the guy was able to tolerate it somewhat. Now I had to find the cords. There was so much blood back there that I nearly pulled out and abandoned everything. The pt wasn't in distress respiratory wise and I hadn't burned any bridges. Plan B was call in people in the middle of the night and we do an awake trach.

As I was in there I proceeded to look around a bit and through all the blood splashing around I was pretty sure I saw where the bubbles were coming from. So I pulled the scope out and cleaned out the blood. Passed some suction down the ETT and tried to clear out as much as possible. I went in one more time and saw the bubbles again. Shot the gap and wala lucky MF'r.

Usually the awake FOI is smooth when well topicalized but this was not the case. He was poorly topicalized and struggling but cooperative the entire time. When I passed thru the cords he started to cough and blood started coming up the ETT. It was a smaller size tube and he could vocalize around it. I was like WTF is going on now. He was not reaching for the tubes s things were ok but I didn't want to paralyze him at all so I turned on the gas and gave a small dose of propofol. Somewhat worried that he tube may have dislodged but I had ETCO2. So I was a thinking I may be just above the cords. As I inflated th cuff he began to cough more. This told me I was probably in the trachea but not 100% sure. I could bag him and there wasn't much of a leak at all so I took the leap of faith and continued to sedate more but slowly in hopes that I could recover if not in. I was definitely taking a chance. He was starting to settle down and I was still getting good ETCO2 and was able to add more air to the cuff. Things were looking good. I went back down with the scope but couldn't see shat due to all the blood in the trachea. So I came out and passed a suction cath. The pt was asleep now and spontaneously breathing well. All was good. Wow what a **** show. Hands down worst airway I have ever seen. Funny thing is that the report from outside hospital was nothing like what we ran into. The ER didn't appreciate the situation either. OMF guy said "I wasn't worried, I knew you would get it".

Follow up, the ICU guy didn't want him to come their way unless he was trach'd. I said, I'm not calling in someone at midnight to trach a secured airway. So we sewed the tube in twice and restrained his arms over night. He got trach'd the next day since we could wake him up with a trach but not with out a tube since the swelling was still quite bad. In my opinion, this guy was going to be a very difficult awake trach at the moment. This ended up being the best of all outcomes. I don't think he would have held still and we would have had to trach him in the sitting position. It would have sucked. Therefore, I felt that this was our best approach. Thank god it worked.

nice management and great discussion.

did you ever get clarity on the etiology of the swelling/benadryl/LOC/tongue lac?

 

[Noyac]

nice management and great discussion.

did you ever get clarity on the etiology of the swelling/benadryl/LOC/tongue lac?

It appears that this guy is a heavy drinker who may have been trying to turn things around. He got a job and was living with his supervisor. He was not drinking since his supervisor was always present and he wanted to keep his job I guess and this led to DT's and the seizure. The Benadryl may or may not have ever happened. I think he was trying to come up with something other than the reality so as not to tip the supervisor off.

 

[Noyac]

What will you do differently next time?

Not sure.
Things actually worked out pretty well. I usually leave a 14 or 16 g catheter in the cric after the transtracheal injection for either jet ventilation or wire to cric. But I wasn't going to sedate this guy so I didn't feel the need to do it in this case.

I would probably call ENT or Gen Surg for trach plan B. But again I didnt think this was a good option since this guy needed to sit upright and I don't think he would have tolerated it well. But it would have been nice to have them.

I would probably just add the hyoid injection. I've never needed it so I'm not so sure how well it works but im pretty sure is would have helped. The transtracheal was smooth but it is quick and I was done before he knew it was coming.

The more I think about this case the more I realize that this was the best approach. I wasn't so sure during and immediately afterwards.

 

[BLADEMDA]

Not sure.
Things actually worked out pretty well. I usually leave a 14 or 16 g catheter in the cric after the transtracheal injection for either jet ventilation or wire to cric. But I wasn't going to sedate this guy so I didn't feel the need to do it in this case.

I would probably call ENT or Gen Surg for trach plan B. But again I didnt think this was a good option since this guy needed to sit upright and I don't think he would have tolerated it well. But it would have been nice to have them.

I would probably just add the hyoid injection. I've never needed it so I'm not so sure how well it works but im pretty sure is would have helped. The transtracheal was smooth but it is quick and I was done before he knew it was coming.

The more I think about this case the more I realize that this was the best approach. I wasn't so sure during and immediately afterwards.

I agree with you except plan B can and does occur in these situations. I know you were ready with plan B but a second, qualified MD involved with the case would be valuable in my opinion.

 

[Noyac]

I agree with you except plan B can and does occur in these situations. I know you were ready with plan B but a second, qualified MD involved with the case would be valuable in my opinion.

The OMF guy has done trachs in the past but not recently to my knowledge. He wasn't useless.

Also, I have done trachs with gen surgeons and they are not fast. ENT is tho.

 

[BLADEMDA]

The OMF guy has done trachs in the past but not recently to my knowledge. He wasn't useless.

Also, I have done trachs with gen surgeons and they are not fast. ENT is tho.

You may have gotten into bleeding doing the cric. Plan B can go smoothly or you can run into complications. Even a slow general surgeon (the guy I had backing me up on a diff airway case one time was useless) may be valuable if fine tuning of the cric is needed or the unanticipated occurs.

 

[deleted547339]

It is easy to say you would crich a pt. in extremis but my reality is that you can't do it without proper supplies. When a pt. is dying or actively losing their airway in front of you in the ED it isn't always easy to have someone run get the exact supplies that you may need. You may have to improvise in a dire situation. I haven't ever done it (nor do I really have the desire to) but one of these days I can see myself doing an emergency airway with a central line kit from the ED.

Knife, boogie, ETT. That's all you need.

 

[deleted547339]

Awesome case.

I'm really glad I went through this in my mind yesterday. I was involved in a surgical airway today and I'm happy to have just mentally prepared. Pt in extremis on arrival to ED, no history. Respiratory distress from a nursing home. JVD, crackles, mental status is nonexistent. Tachycardic with PVCs often, occasional runs of VT. SAT in 70s-80s. BP in the toilet. Patient was prepped for intubation. SAT didn't improve much on nonrebreather with gasping respirations. Patient began to get bradycardic. Pushed drugs, grade 1 view. Couldn't pass a 7.5. Put in a bougie and tried to use that to guide the 7.5. No change - stuck just below cords. Tried 7.0 - No luck. Tried 6.0 - You get the idea. Anesthesia paged - got there quick. Same luck.

This is where I'm glad I went through this mentally yesterday. Surgery paged. Prepped neck, opened the cric kit, had scalpel in hand. Pt SAT improved to 90s with bagging. I was no yet in a "forced to act" situation, so I waited knife in hand. Thankfully, the surgeon got there quick and took over. Had the patient gone brady or hypoxic, I was ready to cut.

Yep, that was my day....

 

[nap$ter]

Awesome case.

I'm really glad I went through this in my mind yesterday. I was involved in a surgical airway today and I'm happy to have just mentally prepared. Pt in extremis on arrival to ED, no history. Respiratory distress from a nursing home. JVD, crackles, mental status is nonexistent. Tachycardic with PVCs often, occasional runs of VT. SAT in 70s-80s. BP in the toilet. Patient was prepped for intubation. SAT didn't improve much on nonrebreather with gasping respirations. Patient began to get bradycardic. Pushed drugs, grade 1 view. Couldn't pass a 7.5. Put in a bougie and tried to use that to guide the 7.5. No change - stuck just below cords. Tried 7.0 - No luck. Tried 6.0 - You get the idea. Anesthesia paged - got there quick. Same luck.

This is where I'm glad I went through this mentally yesterday. Surgery paged. Prepped neck, opened the cric kit, had scalpel in hand. Pt SAT improved to 90s with bagging. I was no yet in a "forced to act" situation, so I waited knife in hand. Thankfully, the surgeon got there quick and took over. Had the patient gone brady or hypoxic, I was ready to cut.

Yep, that was my day....

retrospectively did you find out what his code status was? did he have an old trach scar?

how does a patient arrive from a nursing home without a history/chart?

i imagine you guys tried spinning the tube over the bougie etc...?

did you try bagging/assisting before pushing drugs? gasping respirations on a nonrebreather isn't the greatest preoxygenation...

did you find out what the etiology of the subglottic obstruction was?

 

[deleted171991]

how does a patient arrive from a nursing home without a history/chart?

Usually.

They blame it on the emergency.

I have seen crappy paperwork even in patients sent over for endoscopies.

 

[deleted547339]

retrospectively did you find out what his code status was? did he have an old trach scar?

how does a patient arrive from a nursing home without a history/chart?

i imagine you guys tried spinning the tube over the bougie etc...?

did you try bagging/assisting before pushing drugs? gasping respirations on a nonrebreather isn't the greatest preoxygenation...

did you find out what the etiology of the subglottic obstruction was?

Full code. Tiny, and I mean tiny, trach scar - Honestly, no one noticed it until after the surgeon actually started to cut.

HAHAHAHAHAHA. I guess you've never been in an ER before. I would say about 50% of the patients from the nursing home show up without any real info. Same story today. The RN that normally takes care of him wasn't around; couldn't find the chart; etc. My personal favorite is: They have electronic records and their computer system is down. Oh, and they always go to the community hospital down the street, but we decided to come here today. And they have awful dementia. Med list? What's that? Tag, you're it! Honestly, I was just glad we had a name and date of birth.

Tried spinning the tube. Even tried KY jelly on the tube. Just wasn't happening.

Did not bag. Did true RSI. I know pre-oxygenation wasn't great, but this patient was dying in front of us and I felt like we had to move.

Pt had stenosis from the above-mentioned trach.

The patient was alive when I left the hospital.

 

[deleted171991]

I would have at least tried to preoxygenate, by gently assisting the patient's gasping breaths with synchronized bag-mask ventilation. Nothing to lose, a ton to gain, especially if the patient is bradying. There is also this little thing called LMA; it's regularly used as a backup in difficult airways, and/or as a temporizing measure (less stomach insufflation, better pressure delivery to the trachea).

Patients don't die from being impossible to intubate, just impossible to ventilate. This patient was not the latter, just extremely fatigued from breathing through a thick straw. Did you try to ventilate through the ETT that wouldn't pass, to feel the resistance and buy time?

Also, pushing induction drugs on an already bradying patient... not the best idea.

Do you guys have a jet ventilator in the ER?

 

[deleted547339]

I would have at least tried to preoxygenate, by gently assisting the patient's gasping breaths with synchronized bag-mask ventilation. Nothing to lose, a ton to gain, especially if the patient is bradying. There is also this little thing called LMA; it's regularly used as a backup in difficult airways, and/or as a temporizing measure (less stomach insufflation, better pressure delivery to the trachea).

Patients don't die from being impossible to intubate, just impossible to ventilate. This patient was not the latter, just extremely fatigued from breathing through a thick straw. Did you try to ventilate through the ETT that wouldn't pass, to feel the resistance and buy time?

Also, pushing induction drugs on an already bradying patient... not the best idea.

Do you guys have a jet ventilator in the ER?

I would have definitely preferred to have bagged the patient up, but the patient was literally dying in front of me. Very easy to say "I would have done X, Y and Z," but I had to make a decision. In retrospect, I could have done things differently, but I'm happy with how we managed it, and the patient has done well thus far. I later was able to go through the patient's chart and find that they had presented similarly and arrested a few months back (hence, the trach). As far as not pushing drugs, I felt like the patient was about to code and needed emergent airway management; I wanted my highest chance of first pass success, so I pushed drugs. Mental status was bad, but not 100% unresponsive.

I'm well aware of the LMA. We stock LMAs and iGels. I like and use them both. I considered it, but decided not to use it. It took about 2 minutes between initial DL and knowing I wasn't going to have success with passing a tube. Patient bagged easily and I left the bougie in the trachea the whole time. RN paged anesthesia and I knew they were only a couple minutes away so I didn't think it would be worth putting in an LMA. Maintained good SAT the whole time after bagging.

Anesthesia ended up blowing up the ETT balloon at the level of the cords and we bagged through that. It wasn't great, but it worked.

We do have a jet ventilator, although I've never used it.

 

[deleted171991]

Oh, so you did ventilate. That was the question, basically. Because I hope you realize that's what saved the patient, not the trach.

I am sorry, now I see you did say that, above:

Pt SAT improved to 90s with bagging

I am not trying to be an ass, just to point out that, had you done that before attempting intubation, you might have saved yourself a lot of headache.

 

[deleted547339]

Oh, so you did ventilate. That was the question, basically. Because I hope you realize that's what saved the patient, not the trach.

Oh, yea, definitely. Sorry, I guess I didn't make that clear. We could ventilate fine. The ETT moved from the cords a few times and had to be repositioned, but we maintained SAT in high 90s after we induced. What I was trying to say is that since we were ventilating, I was not in a "forced to act" position regarding a surgical airway. I had the neck prepped and scalpel in hand, but so long as we were maintaining SATs and nothing changed, I was waiting for a surgeon.

 

[deleted171991]

Oh, yea, definitely. Sorry, I guess I didn't make that clear. We could ventilate fine. The ETT moved from the cords a few times and had to be repositioned, but we maintained SAT in high 90s after we induced. What I was trying to say is that since we were ventilating, I was not in a "forced to act" position regarding a surgical airway. I had the neck prepped and scalpel in hand, but so long as we were maintaining SATs and nothing changed, I was waiting for a surgeon.

Now imagine the same situation where you would have had a mass there and would have been unable to ventilate after induction, in a non-preoxygenated patient, and you would have been asked in malpractice court: "Doctor, why didn't you try bag-mask ventilation before you induced and killed the patient?"

Bradycardia is not a reason for inducing without attempting proper preoxygenation, especially when caused by hypoxemia.

 

[deleted547339]

Now imagine the same situation where you would have had a mass there and would have been unable to ventilate after induction, in a non-preoxygenated patient, and you would have been asked in malpractice court: "Doctor, why didn't you try bag-mask ventilation before you induced and killed the patient?"

Bradycardia is not a reason for inducing without attempting proper preoxygenation, especially when caused by hypoxemia.

I'll just keep my snide comments to myself.

 

[deleted171991]

I'll just keep my snide comments to myself.

Please feel free to share. Again, no bad intentions on my part. It's just that I have seen near-misses in the ER, and this sounded like one. Of course, hindsight is 20/20, and I wouldn't dare to comment unless I felt there was a mistake.

From where I stand, there are very few excuses not to actively try to preoxygenate a patient before induction, especially one who runs in the 70s-80s on oxygen mask. Even if induction is needed, I will probably try to mask ventilate first, before attempting to intubate at such a low sat.

My personal near miss in a similar situation was when I induced in a RSI without noticing that my CA-2 had "preoxygenated" the patient with only the mask on, without turning on the O2.

 

[nap$ter]

I would have definitely preferred to have bagged the patient up, but the patient was literally dying in front of me. Very easy to say "I would have done X, Y and Z," but I had to make a decision. In retrospect, I could have done things differently, but I'm happy with how we managed it, and the patient has done well thus far. I later was able to go through the patient's chart and find that they had presented similarly and arrested a few months back (hence, the trach). As far as not pushing drugs, I felt like the patient was about to code and needed emergent airway management; I wanted my highest chance of first pass success, so I pushed drugs. Mental status was bad, but not 100% unresponsive.

I'm well aware of the LMA. We stock LMAs and iGels. I like and use them both. I considered it, but decided not to use it. It took about 2 minutes between initial DL and knowing I wasn't going to have success with passing a tube. Patient bagged easily and I left the bougie in the trachea the whole time. RN paged anesthesia and I knew they were only a couple minutes away so I didn't think it would be worth putting in an LMA. Maintained good SAT the whole time after bagging.

Anesthesia ended up blowing up the ETT balloon at the level of the cords and we bagged through that. It wasn't great, but it worked.

We do have a jet ventilator, although I've never used it.

not to pick your post apart (this is easy to do for any retroscopic non-present physician) but leaving the bougie in the trachea was probably unnecessary (grade 1 view) and may hinder air movement when bagging in the setting of a subglottic stenosis.

also not trying to be an a$$, but i agree with FFP - you appear to have missed his point, which is fundamental to airway management.

the patient was not dying from lack of induction drugs and an endotracheal tube (and dying patients don't need much in the way of intubation drugs) - he was dying from lack of oxygen. the first step is pulling off the nonrebreather and bag-mask ventilating/assisting.

you made the wrong first decision. end of story.

it sounds like (nearly) all of your subsequent decisions were correct - pretty good crisis management/calling for help. we all learn from crises - don't let your ego get in the way of that. again, we are not trying to insult you but rather pointing out a glaring misconception presented by you on an anesthesia forum.

 

[risnwb]

I would have at least tried to preoxygenate, by gently assisting the patient's gasping breaths with synchronized bag-mask ventilation. Nothing to lose, a ton to gain, especially if the patient is bradying. There is also this little thing called LMA; it's regularly used as a backup in difficult airways, and/or as a temporizing measure (less stomach insufflation, better pressure delivery to the trachea).

Patients don't die from being impossible to intubate, just impossible to ventilate. This patient was not the latter, just extremely fatigued from breathing through a thick straw. Did you try to ventilate through the ETT that wouldn't pass, to feel the resistance and buy time?

Also, pushing induction drugs on an already bradying patient... not the best idea.

Do you guys have a jet ventilator in the ER?

Definitely agree with the bag mask assisted pre oxygenation prior to considering moving forward.
Even the most hypoxic obtunded people seem to come up to the mid 90s on the floor after they have been sitting there for hours dying before IM decides to bite the bullet and call us to tube. Thing is, it seems like nobody else in the hospital understands the concept of ASSISTING ventilation and instead I mostly see internal med residents violently pumping away in an attempt to "help" when all they need to do is slow down and pay attention to chest rise.

 

[pgg]

Thanks for posting the case.

I have to admit, when I first read the OP my thought was Go directly to trach, do not pass go. Doing anything nasal in a guy who's now an obligate nose-breather makes me nervous. Though I might try with the neck prepped and the surgeon standing by.

 

[Orin]

What're the thoughts about Glyco or Epi in folks with a history of MI like in this situation? Risk/benefit wise I'm not sure where I land on that spectrum, because as you said, a wet surface is near impossible to topicalize. I should probably review how to do those blocks...

Any thoughts on the old ETT connector to nasal trumpet to vent trick to have some EtCO2, in addition to oxygen insufflation? I've done it for folks with masses for monitoring/extra safety but that's a lot of junk up where I'm working.

 

[deleted171991]

Glyco can be given in 0.1 mg increments. One doesn't have to start with 0.2. It seems to work pretty well for my GA patients.

I don't know the ETT connector trick, but I find having a nasal cannula on high flow O2 pretty helpful during any difficult intubation. Plus it can be connected to an EtCO2 monitor.

 

[Noyac]

What're the thoughts about Glyco or Epi in folks with a history of MI like in this situation? Risk/benefit wise I'm not sure where I land on that spectrum, because as you said, a wet surface is near impossible to topicalize. I should probably review how to do those blocks...

Any thoughts on the old ETT connector to nasal trumpet to vent trick to have some EtCO2, in addition to oxygen insufflation? I've done it for folks with masses for monitoring/extra safety but that's a lot of junk up where I'm working.

I gave him glyco 0.2mg. His HR was already 120 so what was the glyco going to hurt? It didn't even change the HR.

I usually will place a 14-16 angiocath transtracheally when I am concerned that I may lose the airway. I didn't do this initially at this time because I wasn't going to sedate this guy so I didn't see the risk of losing his airway as all that great. But if you place this catheter in the trachea you can take a 7.0 ETT connector and place it in the end of a 3cc syringe with the plunger removed. Then screw this syringe on the carheter and connect the circuit up to it. Turn up your flows and let him continue to breath. Your all good.

 

[okayplayer]

I gave him glyco 0.2mg. His HR was already 120 so what was the glyco going to hurt? It didn't even change the HR.

I usually will place a 14-16 angiocath transtracheally when I am concerned that I may lose the airway. I didn't do this initially at this time because I wasn't going to sedate this guy so I didn't see the risk of losing his airway as all that great. But if you place this catheter in the trachea you can take a 7.0 ETT connector and place it in the end of a 3cc syringe with the plunger removed. Then screw this syringe on the carheter and connect the circuit up to it. Turn up your flows and let him continue to breath. Your all good.

Have you done this before? How much resistance w/ PPV to obtain decent tidal volumes? If they are breathing spontaneously is the work of breathing so high that it makes them fatigue quickly?

 

[Noyac]

Have you done this before? How much resistance w/ PPV to obtain decent tidal volumes? If they are breathing spontaneously is the work of breathing so high that it makes them fatigue quickly?

It's strictly for supplemental O2. If you need to ventilate through this catheter then you need a jet ventilator. You can maintain oxygenation for a surprising length of time. It would have worked well in this case since the bubbles coming up via the cords would have probably been greater. But I can't say I'd do anything differently since everything worked. But had it not worked I would be kicking myself for not doing this.

I use this technique in cases were I am concerned that the airway is worsening, as in angioedema, and that I won't be able to intubate in time. The last time I used this technique was in this very situation. I was pushing a lady up from the ER with severe ACEinh angioedema. Her voice was changing right in front of my eyes. By the time I got her tom the OR she couldn't speak any longer.

 

[urge]

Have you done this before? How much resistance w/ PPV to obtain decent tidal volumes? If they are breathing spontaneously is the work of breathing so high that it makes them fatigue quickly?

Before you attempt that, put a 14g IV in your mouth and try to breath through it. Let's see how long you last. It's too small.

 

[IlDestriero]

What're the thoughts about Glyco or Epi in folks with a history of MI like in this situation? Risk/benefit wise I'm not sure where I land on that spectrum, because as you said, a wet surface is near impossible to topicalize. I should probably review how to do those blocks...

Any thoughts on the old ETT connector to nasal trumpet to vent trick to have some EtCO2, in addition to oxygen insufflation? I've done it for folks with masses for monitoring/extra safety but that's a lot of junk up where I'm working.

We do that often in Peds for fiberoptic intubations.
Vent in one nare and fiber in the other. If he was breathing through his nose, it should work, though increase the risk of nasal bleeding.