Event from Call

[Urzuz]

B/c coughing made the subcutaneous emphesema worse.

When you have rupture of the esophagus, air is able to escape and dissect through the subcutaneous tissue which is what causes the crepitus in Boerhaave's. Coughing -> increased intra-abdominal pressure -> increased air being forced through subcutaneous tissue?

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[Noyac]

Alright, so when are you two gonna stand up and drop your pants so we can see who wins and get on with it?

 

[IlDestriero]

If you think there is a tracheal injury, you really need to use a fiber to see where you are putting the ETT. You don't want to make things worse by putting the ETT through the injured tissue into the mediastinum, or worsening the injury with additional airway trauma.
I've done a few tracheal injuries 2/2 dog bites to the neck, and always used the fiber.

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Il Destriero

 

[Scotty_G]

Does anyone coat the glidescope blade (disposable ones) with local when doing an awake look-technique? I have always topicalized, but what about using some local directly on the blade too?

 

[deleted162650]

Does anyone coat the glidescope blade (disposable ones) with local when doing an awake look-technique? I have always topicalized, but what about using some local directly on the blade too?

The blade will be outta the mouth before it ever gets numb.

 

[tvelocity514]

Our hospital does not have surgeons in house, and this patient was likely not going to last 30-45 minutes to have one called in.
This is how I managed it:
I believed this was Boerhaave, but I was also concerned for tracheal injury. ER doc and I agreed to have trach kit standing by as well as an angiocath. I did a ketamine and versed induction to maintain spontaneous ventilation. I gently slid the glidescope blade into his mouth and confirmed I could find the cords. The entire mouth, posterior pharynx, epiglottis, and cords were edematous, but I could see them. I withdrew the scope and gave succinylcholine, reinserted the Glidescope and tubed him. Ventilation through the tube did not seem to worsen the sub q emphysema, so we were fairly certain at that point it was an esophageal injury (or that the injury was proximal to the ETT cuff, if tracheal). When the sux wore off I gave him a vial of vecuronium to prevent any further coughing, a propofol gtt, and a helicopter ride to a tertiary care facility.

Just curious, if you have the cords visualized, why withdraw and give sux and not just put the tube in? Aren't you worried about not being able to visualize the cords the second time considering you aren't guaranteed to have the same view the second time around?

Doesn't the second time around increase risk of bleeding from friable tissues from the swelling OR worsen swelling from the first intubation OR sux potentially changing the view?
I was just curious bc from what I understand, Sux has side effects and is not a requirement to intubate. Also, the pt is barely sedated so isn't it kind of mean to give a fasciculating paralytic to an awake patient without giving propofol or whatever drug of choice to knock out?

These questions are purely from a learning perspective and not in any way challenging what you did as I'm only an M3. Thanks for the help!

 

[Arch Guillotti]

Just curious, if you have the cords visualized, why withdraw and give sux and not just put the tube in? Aren't you worried about not being able to visualize the cords the second time considering you aren't guaranteed to have the same view the second time around?

Doesn't the second time around increase risk of bleeding from friable tissues from the swelling OR worsen swelling from the first intubation OR sux potentially changing the view?
I was just curious bc from what I understand, Sux has side effects and is not a requirement to intubate. Also, the pt is barely sedated so isn't it kind of mean to give a fasciculating paralytic to an awake patient without giving propofol or whatever drug of choice to knock out?

These questions are purely from a learning perspective and not in any way challenging what you did as I'm only an M3. Thanks for the help!

Good point. I would ram the tube in if I could.

A good view the first time is not a guarantee for the second look after the paralytic has been given.

 

[Noyac]

Good point. I would ram the tube in if I could.

A good view the first time is not a guarantee for the second look after the paralytic has been given.

Do I understand you correctly? Your saying if you see the cords without paralytic you are not guaranteed to see them after coming out and paralyzing the pt.

 

[Robotic Wis-Hipple]

Just curious, if you have the cords visualized, why withdraw and give sux and not just put the tube in? Aren't you worried about not being able to visualize the cords the second time considering you aren't guaranteed to have the same view the second time around?

Doesn't the second time around increase risk of bleeding from friable tissues from the swelling OR worsen swelling from the first intubation OR sux potentially changing the view?
I was just curious bc from what I understand, Sux has side effects and is not a requirement to intubate. Also, the pt is barely sedated so isn't it kind of mean to give a fasciculating paralytic to an awake patient without giving propofol or whatever drug of choice to knock out?

These questions are purely from a learning perspective and not in any way challenging what you did as I'm only an M3. Thanks for the help!

He gave ketamine, which while not the most commonly used or ubiquitously known is still an induction agent, so the patient was in theory unaware (depends on dose of course). This drug was chosen as it provides amnesia and analgesia without negatively impacting respiratory drive as maintaining spontaneous ventilation is important here.

Your other question regarding why not taking the intubation when cords were seen with first look is a good one. Additional instrumentations of the airway do have their negatives as you yourself thought of a few, and in particular increased swelling etc. However, in this setting, there was concern for coughing or gagging on an ETT (especially once the tube is in the trachea with the cuff up) and its potential to worsen the subq emphysema which is likely why sux was given but I cannot speak for the OP. And of course each laryngoscopy brings with it the same potential if the patient is not adequately sedated or successful blunting of laryngeal reflexes is not achieved.

All drugs have side effects, which is why choosing the one you wield in a particular instance absolutely matters, sometimes you can even make "side effects" work for you.

 

[camkiss]

To respond to some of the questions above:
I chose not to run back to the OR to get a fiberoptic because the neck and pharyngeal soft tissue were expanding as we watched. We don't have anesthesia techs in house to run for those things. Furthermore, an ER nurse or tech wouldn't know where to get them if I sent them for it. The Glidescope was immediately available, so I went with it. Our leading diagnosis was Boerhaave, with tracheal rupture a distant second. As for why I did not intubate on the first look, the patient was coughing some during the look, so I did not want to worsen the subq air with trying to pass the tube without paralytic. I probably could have done some topicalization, however at that moment my thoughts were #1: secure an airway and #2: get him to stop coughing and making the swelling worse, which paralyzing him did. I achieved the first look at the cords with minimal effort, so I was reasonably confident I could do so with a second look. As to @tvelocity514, I gave him an induction dose of ketamine, so I was not concerned with recall with paralysis. All good comments, though!

 

[Noyac]

Very well done. That's Rockstar status.

 

[tvelocity514]

To respond to some of the questions above:
I chose not to run back to the OR to get a fiberoptic because the neck and pharyngeal soft tissue were expanding as we watched. We don't have anesthesia techs in house to run for those things. Furthermore, an ER nurse or tech wouldn't know where to get them if I sent them for it. The Glidescope was immediately available, so I went with it. Our leading diagnosis was Boerhaave, with tracheal rupture a distant second. As for why I did not intubate on the first look, the patient was coughing some during the look, so I did not want to worsen the subq air with trying to pass the tube without paralytic. I probably could have done some topicalization, however at that moment my thoughts were #1: secure an airway and #2: get him to stop coughing and making the swelling worse, which paralyzing him did. I achieved the first look at the cords with minimal effort, so I was reasonably confident I could do so with a second look. As to @tvelocity514, I gave him an induction dose of ketamine, so I was not concerned with recall with paralysis. All good comments, though!

Awesome, thanks for the feedback. Great Case! Thanks for sharing!


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[Arch Guillotti]

Do I understand you correctly? Your saying if you see the cords without paralytic you are not guaranteed to see them after coming out and paralyzing the pt.

yes

 

[Noyac]

yes

Well if you are going by the mantra that there are no guarantees in life, then maybe. Otherwise, that's pretty damn close to a guarantee.