How would you have approached this airway?

[bike detroit]

I recently read this post on Scott Weingart's emcrit.org blog about an elective cric performed on a patient with his jaw wired-shut. There is a video that describes the case and shows the actual procedure.

Paraphrasing the case from the video: the patient broke his jaw a few weeks earlier and had it wired shut. Fast forward a few weeks, he was having coffee with his buddies when he developed chest pain and then went into v-fib. He gets coded in the field and brought into the hospital. In the ED his level of conscious is eyes open, not responsive to voice, but has purposeful movements. He is normal sinus, stable bp, and agonal respirations (based on what I saw in the video. MS2 here, haven't seen them yet in real life). The EM guys first consider cutting the wires and intubating, but quickly decide to go right to the cric.

I am curious as to what other airway options (if any?) they could have considered before the cric from an anesthesiologist's perspective.

Here is the video:

---

Members don't see this ad.

 

[bike detroit]

Also, here is what Dr. Weingart posted in the comments:

"I am closing comments on this post as there have been many comments from Monday morning QBs. To respond to most of these comments:
1. NT is a bad idea in a patient with a wired jaw in a non-elective situation. If he starts bleeding, it is a bad scene.
2. This patient is meta-stable, not stable. This was emergent airway management. The patient had already had multiple codes and was having runs of v. tach while the procedure was performed. This was the most rapid and appropriate means of controlling the airway.
3. The NAP4 study is worth a read for those that don’t believe a cric should be done until you are well down the path of airway disaster.
4. There was a question about the aerosoliized blood being from the NIPPV–I have gotten this spray with all crics.
5. Yes, they could have cut the jaw wires and tried oral. This adds task complexity and may still be difficult airway and then the pt would have required RSI. Awake cric in this patient with perfect anatomy is probably the ideal way to go."

 

[chmd]

Retrograde

 

[norwood]

Yes, they could have cut the jaw wires and tried oral. This adds task complexity and may still be difficult airway and then the pt would have required RSI

Bold text is mine - what is this "and then the pt would have required RSI"? Does he mean "then we'd have needed to give sux"?

ETA: I realize you're just quoting the original guy, but I still don't get what he's saying there. It's either RSI from the beginning or it's not.

 

[bike detroit]

Is bleeding (ie epistaxis) a common complication of nasal and retrograde-nasal intubations?

 

[OB1🤙]

So what I do for an awake nasal (which I haven't had to do in literally years) is take a nasal trumpet and cut it lengthwise. Grease it up and put it down a vasoconstricted nostril.

This gives you an atraumatic conduit for your nasal instrumentation, and tamponades whatever bleeding you may otherwise stir up.

So if I had been in their situation, I may have tried that first.

But I think their management of this particular patient, who was sick as hell, was excellent.

 

[Urzuz]

Hard to know exactly what I would have done, as being in the ED with a patient like that is a lot different than sitting behind my computer screen thinking about it. But if at that moment he was semi-stable, I would have probably sent for the wire cutters emergently and planned on RSI with direct laryngoscopy as plan A. While waiting for the wire cutters I would still have everything else set up and ready to go (cric equipment, fiber, neck prepped, etc).

Something else to mention -- in the video they talked about potentially calling ENT to do an elective trach, but they didn't feel like the patient was stable enough for that procedure. I can understand that justification. However, if it were me, I would still call ENT...if for nothing else then to have them stand there while I carry out my plan A after the wire cutters arrived. If things started to head south, they would be there to perform the urgent/emergent cric then.

All that said, major props to the ED doc and the team who saved this guys life. Handled it like a boss.

 

[Planktonmd]

This was the most appropriate airway management under the circumstances described.

 

[nap$ter]

the ER saves a lot of lives by not delaying emergent procedures like IO's and emergent crikes - they had a good outcome here - props to em.

HOWEVER - from my anesthesiologist perspective this should have been done differently. You have a meta-stable patient - good BP, HR, adequate ventilation and oxygenation. It takes literally 5 seconds to clip the wires holding the jaw shut - the ENT's put these wires in conspicuous places and there are only a couple holding the mouth closed.

Call for your crike materials and the wire cutter. Clip the wires, RSI, oral ett. I think this could have been done faster than the crike, and without an incision. And even with great anatomy what is plan B if the pt crumps and you can't get the crike right away? still gonna have to clip those wires...

I would stay away from the nose - bleeding is common even with vasoconstricters/trumpets/red rubbers/lube etc...

 

[Ignatius J]

Would go straight to the Trach if unstabile and have someone working on the wires simultaneously for plan B.

If stabile, cut the wires and put the tube in.

 

[deleted682700]

Thanks. Anesthesiologists can learn from this one do this and save disasters. Very cool