Trauma Case

[BLADEMDA]

Here is the situation:

You are called to the E.R. for a trauma. A guy wrecked his motorcycle (harley of course). He is stable but has severe wounds to his left leg. He also has neck pain. Patient weights 280 pounds and is 5'10".

On arrival to the trauma bay the patient is there. Personal belongings and cell phone. The nurse is talking to the patient's wife and trying to get a history.
You overhear DM, CABG X4 in '01, Porphyria and HTN.

Vitals are BP=185/110 HR=125 Sat=99% on non rebreather. THe nurse get two IV's and the trauma Ortho dude wants to go to the OR after CT. The leg looks bad and has a tourniquet on it. Ortho dude thinks amputation is likely.

CT scan should take 12-15 minutes and then the O.R. CT scan of the neck will be performed along with left lower extremity.

What is your plan? The patient has big ZZ top looking beard and a bull neck.
Leforte 1 fracture likely per ENT.

What you gonna do?

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[BLADEMDA]

 

[BLADEMDA]

 

[Noyac]

Porphyria can be exacerbated by trauma, stress, etc.

What type is it?

 

[BLADEMDA]

Porphyria can be exacerbated by trauma, stress, etc.

What type is it?

http://www.merck.com/mmhe/sec12/ch160/ch160c.html

AIP

 

[Leverage]

interestingly...barbiturates can increase porphyrins...no thiopental for this biker.

probably not in anyones plan but good test point.

pretty sure that is in baby miller.

 

[SleepIsGood]

looks semi stable here....potentially bad a/w with neck pain indicating cervical injx.

Since I'm newly minted....I say topicalize the a/w with inhaled lido. block through the crico membrane. also some benzocaine spray. Also some lido s/s. in line stabilization. Sorry sir, this may be a little unfortable. Awake glidescope....etomidate..roc...do the case.

 

[lushmd]

:Awake glidescope....

Why awake glidescope and not awake FOI (just seems less stimulating)?


Anyway, back to the case:

(1) Quick pre-op and description/discussion of anesthetic plan (focused on any prior anesthetic complications, exercise tolerance, cardiac signs/symptoms given hx, inquiring into if pt has had a prior AIP attack and if so when etc..., and preparing pt for awake intubation).

(2) Into the room, standard monitors, pre-oxygenate.

(3) Re airway management, I think we all agree that some sort of awake intubation is indicated. Personally, I would go with awake fiberoptic. The question is how to accomplish this. Medications best avoided in acute intermittent porphyria include barbiturates, etomidate, lidocaine as well as possibly midazolam and ketamine. As such, topicalization with lidocaine (as we would otherwise be apt to do) is out. Perhaps a reasonable approach would be to topicalize with benzocaine (hurricane spray) and sedate with precedex (failing that, a little propofol). Then awake FOI with someone holding in-line stabilization in case pt tries to move his neck.

(4) Once he's intubated (with EtCO2 etc...), induce with a modest dose of propofol, turn on volatile agent of choice (no halothane, not that its even an option), and give a non-depolarizing NMB. 2 large bore PIVs, blood available, and arterial line.

(5) Although AIP can certainly be exacerbated by stress, I don't think that there's a reason to treat it pre-emptively. As mentioned previously, avoid potential triggering agents. If there's high index of suspicion for an AIP attack (red urine and/or hyponatremia on the ABG), one can check ALA levels and/or check for urine porphyrins.

So Blade, what was your approach?

 

[lord_jeebus]

As such, topicalization with lidocaine (as we would otherwise be apt to do) is out?

This sounded suspect to me and I looked it up. Per Stoelting, "There is no evidence that any local anesthetic has ever induced an acute attack of porphyria or neurologic damage in porphyric individuals."

 

[Planktonmd]

The porphyria would be probably at the bottom of my list of concerns in this patient, just don't use Thiopental, keep warm and resuscitate the patient aggressively (like any trauma patient).

Patient is morbidly obese with a facial fracture and unknown status of the cervical spine, I am assuming he is relatively cooperative at this point.
Your first priority is to secure the airway before more oral edema and bleeding complicate the picture.
Give some narcotics and Glycopyrolate to control the pain and the secretions.
If the BP remains elevated I might add a little betablocker considering the cardiac history.
Good topical anesthesia, a transtracheal block and even a superior laryngeal block (if you like) would be the key here, then how you intubate depends on how much airway bleeding there is and on what airway toy you prefer.
Do not try to intubate nasally.
If you can clean the airway of blood FOB is still a good option but any other airway device would be OK as long you keep him awake and breathing spontaneously.
Once the airway is secure this case is straight forward.

 

[ProRealDoc]

Why awake glidescope and not awake FOI (just seems less stimulating)?


Anyway, back to the case:

(1) Quick pre-op and description/discussion of anesthetic plan (focused on any prior anesthetic complications, exercise tolerance, cardiac signs/symptoms given hx, inquiring into if pt has had a prior AIP attack and if so when etc..., and preparing pt for awake intubation).

(2) Into the room, standard monitors, pre-oxygenate.

(3) Re airway management, I think we all agree that some sort of awake intubation is indicated. Personally, I would go with awake fiberoptic. The question is how to accomplish this. Medications best avoided in acute intermittent porphyria include barbiturates, etomidate, lidocaine as well as possibly midazolam and ketamine. As such, topicalization with lidocaine (as we would otherwise be apt to do) is out. Perhaps a reasonable approach would be to topicalize with benzocaine (hurricane spray) and sedate with precedex (failing that, a little propofol). Then awake FOI with someone holding in-line stabilization in case pt tries to move his neck.

(4) Once he's intubated (with EtCO2 etc...), induce with a modest dose of propofol, turn on volatile agent of choice (no halothane, not that its even an option), and give a non-depolarizing NMB. 2 large bore PIVs, blood available, and arterial line.

(5) Although AIP can certainly be exacerbated by stress, I don't think that there's a reason to treat it pre-emptively. As mentioned previously, avoid potential triggering agents. If there's high index of suspicion for an AIP attack (red urine and/or hyponatremia on the ABG), one can check ALA levels and/or check for urine porphyrins.

So Blade, what was your approach?

The porphyrinogenicity of etomidate and ketamine appears to be related more to infusions rather than boluses. However, others claim it should be avoided even as a single bolus while others report safe use. If given a choice I'd probably choose an alternative drug but would not hesitate to use etomidate if needed be.

 

[BLADEMDA]

Why awake glidescope and not awake FOI (just seems less stimulating)?


Anyway, back to the case:

(1) Quick pre-op and description/discussion of anesthetic plan (focused on any prior anesthetic complications, exercise tolerance, cardiac signs/symptoms given hx, inquiring into if pt has had a prior AIP attack and if so when etc..., and preparing pt for awake intubation).

(2) Into the room, standard monitors, pre-oxygenate.

(3) Re airway management, I think we all agree that some sort of awake intubation is indicated. Personally, I would go with awake fiberoptic. The question is how to accomplish this. Medications best avoided in acute intermittent porphyria include barbiturates, etomidate, lidocaine as well as possibly midazolam and ketamine. As such, topicalization with lidocaine (as we would otherwise be apt to do) is out. Perhaps a reasonable approach would be to topicalize with benzocaine (hurricane spray) and sedate with precedex (failing that, a little propofol). Then awake FOI with someone holding in-line stabilization in case pt tries to move his neck.

(4) Once he's intubated (with EtCO2 etc...), induce with a modest dose of propofol, turn on volatile agent of choice (no halothane, not that its even an option), and give a non-depolarizing NMB. 2 large bore PIVs, blood available, and arterial line.

(5) Although AIP can certainly be exacerbated by stress, I don't think that there's a reason to treat it pre-emptively. As mentioned previously, avoid potential triggering agents. If there's high index of suspicion for an AIP attack (red urine and/or hyponatremia on the ABG), one can check ALA levels and/or check for urine porphyrins.

So Blade, what was your approach?

1. I would avoid Etomidate as its use in AIP is controversial. A few studies show it can be used but textbooks don't recommend in AIP:

http://books.google.com/books?id=xa...date and acute intermittent porphyria&f=false

2. Leforte 1 Fracture- Med Student asks if we can do awake Nasal intubation?

3. Cervical Spine Fracture - C6-C7.



Stat Hemoglobin is now 8.7 Patient is on his way to the OR. Blood bank doesn't have type specific blood ready yet. Ortho dude expects at least another 800-1000 of EBL. He wants to proceed ASAP.

Anesthestic Plan?

 

[BLADEMDA]

While main issue here is NOT the patient's AIP some believe it must be considered in the perioperative/intraoperative care of this patient.

Here is Dr. Neils Jensen:

http://www.boardprep.com/pdfs/porphyria.pdf (read page 11)


http://www.anesthesia-analgesia.org/content/80/3/591.full.pdf (look at Etomidate on the chart)

Med Student asks about giving the Obese patient Reglan (metoclopramide) and Zantac (Ranitidine) in the E.R. because he ate 2 hours ago. Would it help this patient? Is it contraindicated?

What is your plan intraoperatively? Old record indicates EF was 35% last year. No chest pain since the CABG in '01.

 

[Planktonmd]

While main issue here is NOT the patint's AIP some believe it must be considered in the perioperative/intraoperative care of this patient.

Here is Dr. Neils Jensen:

http://www.boardprep.com/pdfs/porphyria.pdf (read page 11)

What Jensen says has nothing to do with what happens in the real world

 

[BLADEMDA]

This sounded suspect to me and I looked it up. Per Stoelting, "There is no evidence that any local anesthetic has ever induced an acute attack of porphyria or neurologic damage in porphyric individuals."

Correct. Now look up Etomidate and Ketamine. While you are at it look up Reglan and Zantac as well.

 

[BLADEMDA]

Why awake glidescope and not awake FOI (just seems less stimulating)?


Anyway, back to the case:

(1) Quick pre-op and description/discussion of anesthetic plan (focused on any prior anesthetic complications, exercise tolerance, cardiac signs/symptoms given hx, inquiring into if pt has had a prior AIP attack and if so when etc..., and preparing pt for awake intubation).

(2) Into the room, standard monitors, pre-oxygenate.

(3) Re airway management, I think we all agree that some sort of awake intubation is indicated. Personally, I would go with awake fiberoptic. The question is how to accomplish this. Medications best avoided in acute intermittent porphyria include barbiturates, etomidate, lidocaine as well as possibly midazolam and ketamine. As such, topicalization with lidocaine (as we would otherwise be apt to do) is out. Perhaps a reasonable approach would be to topicalize with benzocaine (hurricane spray) and sedate with precedex (failing that, a little propofol). Then awake FOI with someone holding in-line stabilization in case pt tries to move his neck.

(4) Once he's intubated (with EtCO2 etc...), induce with a modest dose of propofol, turn on volatile agent of choice (no halothane, not that its even an option), and give a non-depolarizing NMB. 2 large bore PIVs, blood available, and arterial line.

(5) Although AIP can certainly be exacerbated by stress, I don't think that there's a reason to treat it pre-emptively. As mentioned previously, avoid potential triggering agents. If there's high index of suspicion for an AIP attack (red urine and/or hyponatremia on the ABG), one can check ALA levels and/or check for urine porphyrins.

So Blade, what was your approach?

Not so fast. I like most of your answers but avoiding Lidocaine here isn't correct. Tell me about the full stomach. What is your approach and philosophy concerning premeds, Diabetics and this patient with AIP?

What about his C6-C7 fracture? Does that mandate an awake FOI? What about his Leforte 1 fracture? Can you go nasally here? Will you consider it?

Tell me about his AIP and hypovolemia (HGb 8.7). Will you transfuse? At what level? How many units of non type specific blood will you give him?
What about the EF of 35%? Is CVP monitoring indicated in this obese patient with AIP and large blood loss? Do you want an A-line prior to induction? Why or why not?

 

[BLADEMDA]

It doesn't matter what Blade does here. What matters is that you are or will be a Consultant in Anesthesiology. This means you can answer/defend your approach in this case. While "experience" is very important please remember to include peer reviewed literature in any controversial areas. IMHO, every area is controversial and requires substantiation. That is why we go to Medical School and do a Residency.

Blade

 

[Planktonmd]

It doesn't matter what Blade does here. What matters is that you are or will be a Consultant in Anesthesiology. This means you can answer/defend your approach in this case. While "experience" is very important please remember to include peer reviewed literature in any controversial areas. IMHO, every area is controversial and requires substantiation. That is why we go to Medical School and do a Residency.

Blade

Everything is controversial as long as you want it to be controversial.
People who live in imaginary worlds tend to see zebras at every corner.
"experience" is what differentiate a clinician from a parrot (parrots tend to regurgitate every word they hear or see on the internet).
Any one can copy and paste stuff from google but only a good clinician can filter the 90% BS that people tend to copy and paste.

 

[amyl]

Not so fast. I like most of your answers but avoiding Lidocaine here isn't correct. Tell me about the full stomach. What is your approach and philosophy concerning premeds, Diabetics and this patient with AIP?

What about his C6-C7 fracture? Does that mandate an awake FOI? What about his Leforte 1 fracture? Can you go nasally here? Will you consider it?

Tell me about his AIP and hypovolemia (HGb 8.7). Will you transfuse? At what level? How many units of non type specific blood will you give him?
What about the EF of 35%? Is CVP monitoring indicated in this obese patient with AIP and large blood loss? Do you want an A-line prior to induction? Why or why not?

no reglan, opinions mixed on effectiveness and DM gastroparesis anyways -- ordinarily would give it, but not here with porphyria. would avoid nasal if at all possible w leforte 1 and prefer awake FOI over glidescope but might have it nearby. aline prior to induction and cvp after. transfuse when hemodynamically called for.
ha, really a case that you cant "pent sux tube." thanks blade

 

[BLADEMDA]

So you examine the airway and the mouth is pretty bloody. Looks like the guy's nose is broken as well.

Now, still want to do awake FOI?

What about intraoperative monitoring and the patient's hypovolemia? Does everyone concur with Amyl?
Any concern with AIP?

Does his EF of 35% alter your plan in anyway? If so, how?

Blood bank just sent you 2 units of 0+ emergency release blood. They haven't got type specific blood but patient tells you he is AB-. Are you going to give the emergency blood or wait for AB-?

 

[BLADEMDA]

Everything is controversial as long as you want it to be controversial.
People who live in imaginary worlds tend to see zebras at every corner.
"experience" is what differentiate a clinician from a parrot (parrots tend to regurgitate every word they hear or see on the internet).
Any one can copy and paste stuff from google but only a good clinician can filter the 90% BS that people tend to copy and paste.

No. I live in the real world and that means backing up my statements/approach with both experience and peer reviewed literature. If you have more to add about the case then please feel free to do so.
Thanks.

 

[BLADEMDA]

no reglan, opinions mixed on effectiveness and DM gastroparesis anyways -- ordinarily would give it, but not here with porphyria. would avoid nasal if at all possible w leforte 1 and prefer awake FOI over glidescope but might have it nearby. aline prior to induction and cvp after. transfuse when hemodynamically called for.
ha, really a case that you cant "pent sux tube." thanks blade

Yes. This patient is 56 years old and is gainfully employed. He owns several businesses in the area and even has commercial insurance.

Good answer by the way.

 

[lushmd]

Not so fast. I like most of your answers but avoiding Lidocaine here isn't correct. Tell me about the full stomach. What is your approach and philosophy concerning premeds, Diabetics and this patient with AIP?

What about his C6-C7 fracture? Does that mandate an awake FOI? What about his Leforte 1 fracture? Can you go nasally here? Will you consider it?

Tell me about his AIP and hypovolemia (HGb 8.7). Will you transfuse? At what level? How many units of non type specific blood will you give him?
What about the EF of 35%? Is CVP monitoring indicated in this obese patient with AIP and large blood loss? Do you want an A-line prior to induction? Why or why not?

Good to know re lidocaine and AIP (I was going off memory).

Full stomach: Certainly a concern in any trauma patient, particularly one with DM. Having said that, as Amyl pointed out, reglan isn't a good option due to AIP. You won't have enough time for pepcid to take effect and you can't sit this pt with a C-spine fx up to drink bicitra. No pre-induction NGT due to facial fx. So, have suction available during awake FOI and then post-induction OGT. EDIT: Re now bloody airway. Suction well prior to attempting awake FOI. If still unable to do awake FOI, attempt awake glidescope.

C6-7 fx: This alone does not mandate awake FOI. Rather, awake FOI is indicated due to likely difficult to ventilate/intubate situation (obese, beard, short/thick neck, no CROM). The LeForte I fx precludes nasal intubation.

Hypovolemia/Anemia: In this pt, with CAD and AIP undergoing a potentially bloody surgery with a Hgb of 8.7, I'd transfuse one unit of PRBC to start with and aim to maintain Hgb ~10. Pre-induction a-line can be done (usually well tolerated with local anesthesia and a bit of sedation) but isn't something I feel is necessary. Likewise, at this point, I don't see the need for central access unless there isn't adequate peripheral access (i.e. 2 16g PIVs or better).

 

[BLADEMDA]

Anyone care to comment on glucose management and temperature control in this patient? Do they matter?

 

[BLADEMDA]

Good to know re lidocaine and AIP (I was going off memory).

Full stomach: Certainly a concern in any trauma patient, particularly one with DM. Having said that, as Amyl pointed out, reglan isn't a good option due to AIP. You won't have enough time for pepcid to take effect and you can't sit this pt with a C-spine fx up to drink bicitra. No pre-induction NGT due to facial fx. So, have suction available during awake FOI and then post-induction OGT. EDIT: Re now bloody airway. Suction well prior to attempting awake FOI. If still unable to do awake FOI, attempt awake glidescope.

C6-7 fx: This alone does not mandate awake FOI. Rather, awake FOI is indicated due to likely difficult to ventilate/intubate situation (obese, beard, short/thick neck, no CROM). The LeForte I fx precludes nasal intubation.

Hypovolemia/Anemia: In this pt, with CAD and AIP undergoing a potentially bloody surgery with a Hgb of 8.7, I'd transfuse one unit of PRBC to start with and aim to maintain Hgb ~10. Pre-induction a-line can be done (usually well tolerated with local anesthesia and a bit of sedation) but isn't something I feel is necessary. Likewise, at this point, I don't see the need for central access unless there isn't adequate peripheral access (i.e. 2 16g PIVs or better).

Does a Leforte 1 absolutely preculde a nasal intubation? What about a lefort 2 or leforte 3?

Does blood in the mouth concern you for your awake FOI? Will it hurt your chances of success?

 

[Planktonmd]

No. I live in the real world and that means backing up my statements/approach with both experience and peer reviewed literature. If you have more to add about the case then please feel free to do so.
Thanks.

OK,
I already told you what I would do, but I will repeat it for you since I love you.
Give Glyopyrolate and some opiate, then give a beta blocker if the BP is still elevated.
After that do an excellent topical anesthetic and whatever airway blocks you know how to do (i doubt that you don't really know many of those), using LIDOCAINE and ignoring all the BS about Lidocaine being contra indicated in patients with Prophyria.
Then intubtae AWAKE using whatever method you like.
After that maintain anesthesia the way you do with any trauma patient and once again ignoring all the BS about prophyria that seems to upset you so much.
If he develops an acute porphyric episode then treat it.
And please do not give Reglan, Pepcid or any other masturbatory medication.
Does that plan sound reasonable to you professor?
And as I said to you earlier, Do not do a nasal intubation regardless what Leforte classification the fracture is.

 

[BLADEMDA]

OK,
I already told you what I would do, but I will repeat it for you since I love you.
Give Glyopyrolate and some opiate, then give a beta blocker if the BP is still elevated.
After that do an excellent topical anesthetic and whatever airway blocks you know how to do (i doubt that you don't really know many of those), using LIDOCAINE and ignoring all the BS about Lidocaine being contra indicated in patients with Prophyria.
Then intubtae AWAKE using whatever method you like.
After that maintain anesthesia the way you do with any trauma patient and once again ignoring all the BS about prophyria that seems to upset you so much.
If he develops an acute porphyric episode then treat it.
And please do not give Reglan, Pepcid or any other masturbatory medication.
Does that plan sound reasonable to you professor?
And as I said to you earlier, Do not do a nasal intubation regardless what Leforte classification the fracture is.

http://www.ncbi.nlm.nih.gov/pubmed/9144052

 

[Planktonmd]

http://www.ncbi.nlm.nih.gov/pubmed/9144052

Why do you feel you need to intubate nasally???
How do you know what kind of fracture you are dealing with since you don't even have a ct scan yet?

 

[BLADEMDA]

Why do you feel you need to intubate nasally???
How do you know what kind of fracture you are dealing with since you don't even have a ct scan yet?

CT Scan done. Lefort 1 confirmed.


Nasal intubation was traditionally contraindicated in LeFort II or III fractures because of the possible disruption of the cribriform plate and the risk of cranial intubation 6,7 or meningitis. 2,8,9 However, several reports have described the successful placement of a nasotracheal tube over a fiber-optic bronchoscope without cranial intubation or other complications. 10,11 Therefore, in certain cases a nasotracheal tube has been used instead of elective tracheostomy to facilitate the surgical alignment and repair of LeFort II and III fractures.


http://journals.lww.com/anesthesiol...ression_of_a_Nasotracheal_Tube_due_to.45.aspx

 

[BLADEMDA]

Nasal Intubation is NOT my prefered choice in any Lefort fracture. However, Lefort 1 fractures are much less "dangerous" than Lefort 2 or 3.

I wanted the Residents to know there is a distinction between them.

 

[Planktonmd]

Nasal Intubation is NOT my prefered choice in any Lefort fracture. However, Lefort 1 fractures are much less "dangerous" than Lefort 2 or 3.

I wanted the Residents to know there is a distinction between them.

Sorry, I couldn't resist posting this image:

 

[gtb]

Thank you Blade for posting the case and encouraging discussion.

My summary is that this is an obese, major trauma patient with DM and likely facial fractures, and possibly difficult airway. Maybe it's a Lefort I, but w/o CT scans, it might be a II or III. Could also have b/l mandibular fractures or anything else not apparent on plain films. Might or might not have a TBI. All the Harley riders that I have seen do not wear decent helmets. I'm going to assume the worse.

Agree with all the other strategies except airway management. For me, my plan is PreO2, RSI (front collar removed, bed in rvrs trend, inline stabilization, touch his cricoid, titrate propofol, SCC), and then airway with DL -> fiberoptic larygoscopy -> FOB (if no bleeding to obscure fiber) -> surgical airway as last resort. Especially in this setting of trauma, DM, obesity, unknown NPO status, potential cervical spine injury, facial trauma that might start bleeding when the mouth is opened.

Also needs a glucose infusion since starvation can precipitate inducible types of pophyria.

 

[BLADEMDA]

Thank you Blade for posting the case and encouraging discussion.

My summary is that this is an obese, major trauma patient with DM and likely facial fractures, and possibly difficult airway. Maybe it's a Lefort I, but w/o CT scans, it might be a II or III. Could also have b/l mandibular fractures or anything else not apparent on plain films. Might or might not have a TBI. All the Harley riders that I have seen do not wear decent helmets. I'm going to assume the worse.

Agree with all the other strategies except airway management. For me, my plan is PreO2, RSI (front collar removed, bed in rvrs trend, inline stabilization, touch his cricoid, titrate propofol, SCC), and then airway with DL -> fiberoptic larygoscopy -> FOB (if no bleeding to obscure fiber) -> surgical airway as last resort. Especially in this setting of trauma, DM, obesity, unknown NPO status, potential cervical spine injury, facial trauma that might start bleeding when the mouth is opened.

Also needs a glucose infusion since starvation can precipitate inducible types of pophyria.

Nice Answer. I did exactly what you listed above but had Glidescope in the room along with trauma surgeon. The guy had his CABG at my institution and I had a pretty good idea who intubated him.

Since he had a "Biggie meal" at Burger King just 2 hours ago with extra large fries does he really need that glucose infusion? Do you want a blood glucose reading or will you just start glucose and insulin anyway?

If you decide on an arterial line will you place prior to induction? Since you chose Propofol any concern in a hypovolemic patient with an EF of 35%? Where will you place your CVP?

You are right about the crappy helmet.

 

[Planktonmd]

So, you are saying that the best way to secure an airway in a morbidly obese patient with a cervical fracture and a facial fracture is to make him apneic and abolish all his airway reflexes and then hope you could intubate him before he dies?

Thank you Blade for posting the case and encouraging discussion.

My summary is that this is an obese, major trauma patient with DM and likely facial fractures, and possibly difficult airway. Maybe it's a Lefort I, but w/o CT scans, it might be a II or III. Could also have b/l mandibular fractures or anything else not apparent on plain films. Might or might not have a TBI. All the Harley riders that I have seen do not wear decent helmets. I'm going to assume the worse.

Agree with all the other strategies except airway management. For me, my plan is PreO2, RSI (front collar removed, bed in rvrs trend, inline stabilization, touch his cricoid, titrate propofol, SCC), and then airway with DL -> fiberoptic larygoscopy -> FOB (if no bleeding to obscure fiber) -> surgical airway as last resort. Especially in this setting of trauma, DM, obesity, unknown NPO status, potential cervical spine injury, facial trauma that might start bleeding when the mouth is opened.

Also needs a glucose infusion since starvation can precipitate inducible types of pophyria.

 

[BLADEMDA]

What about intraoperative monitoring and the patient's hypovolemia? Does everyone concur with Amyl?
Any concern with AIP?

Does his EF of 35% alter your plan in anyway? If so, how?

Blood bank just sent you 2 units of 0+ emergency release blood. They haven't got type specific blood but patient tells you he is AB-. Are you going to give the emergency blood or wait for AB-?

So, I put the arterial line in. Takes 35 seconds. ABG comes back with the following: 7.29/34/146 BE-14 Hemoglobin now 7.7

Careful induction with Propofol, 200 ug phenylephrine and Sux. Miller Blade and RSI (if it works). Cervical immobilization. Posterior Collar left in place. 8.0 et tube placed on first attempt. ETCO2, BBS.

Now, what about the ABG and the hemoglobin?

 

[BLADEMDA]

So, you are saying that the best way to secure an airway in a morbidly obese patient with a cervical fracture and a facial fracture is to make him apneic and abolish all his airway reflexes and then hope you could intubate him before he dies?

No. You are saying that. I posted what I did for this patient.

 

[Planktonmd]

No. You are saying that. I posted what I did for this patient.

You put the guy to sleep, gave a muscle relaxant and hoped for the best!
You were able to intubate him (luckily) but I am not sure why you feel that gambling with the patient's life is a great idea?

Knowing that someone was able to intubate him electively before does not make it OK to risk his life now, since now you are dealing with a different set of circumstances (cervical fracture, Facial fracture, airway bleeding...)

 

[BLADEMDA]

You put the guy to sleep, gave a muscle relaxant and hoped for the best!
You were able to intubate him (luckily) but I am not sure why you feel that gambling with the patient's life is a great idea?

Knowing that someone was able to intubate him electively before does not make it OK to risk his life now, since now you are dealing with a different set of circumstances (cervical fracture, Facial fracture, airway bleeding...)

Not just "someone" as you put it. An Anesthesiologist at my institution.
Also, there was a truama surgeon in the room ready to assist. Plus, Glidecope, Diff. Airway cart, etc.

I do respect your opinion as the the "awake" intubation on this patient.
But, I believe the vast majority of trauma patients in the USA are still just RSI "asleep" intubations.


http://www.anesthesia.org/winterlude/wl95/wl95_1.html

 

[BLADEMDA]

Anesth Analg. 2009 Sep;109(3):866-72.
The success of emergency endotracheal intubation in trauma patients: a 10-year experience at a major adult trauma referral center.

Stephens CT, Kahntroff S, Dutton RP.
Division of Trauma Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
Abstract

BACKGROUND: Emergency airway management is a required skill for many anesthesiologists. We studied 10 yr of experience at a Level 1 trauma center to determine the outcomes of tracheal intubation attempts within the first 24 h of admission. METHODS: We examined Trauma Registry, quality management, and billing system records from July 1996 to June 2006 to determine the number of patients requiring intubation within 1 h of hospital arrival and to estimate the number requiring intubation with the first 24 h. We reviewed the medical record of each patient in either cohort who underwent a surgical airway access procedure (tracheotomy or cricothyrotomy) to determine the presenting characteristics of the patients and the reason they could not be orally or nasally intubated. RESULTS: All intubation attempts were supervised by an anesthesiologist experienced in trauma patient care. Rapid sequence intubation with direct laryngoscopy was the standard approach throughout the study period. During the first hour after admission, 6088 patients required intubation, of whom 21 (0.3%) received a surgical airway. During the first 24 h, 10 more patients, for a total of 31, received a surgical airway, during approximately 32,000 attempts (0.1%). Unanticipated difficult upper airway anatomy was the leading reason for a surgical airway. Four of the 31 patients died of their injuries but none as the result of failed intubation. CONCLUSIONS: In the hands of experienced anesthesiologists, rapid sequence intubation followed by direct laryngoscopy is a remarkably effective approach to emergency airway management. An algorithm designed around this approach can achieve very high levels of success.

 

[Planktonmd]

One last remark here:
This was not an "Emergency" airway management, it was urgent but not an emergency.
You made it an emergency the moment you injected Propofol + Sux.
You turned a spontaneously breathing airway protecting patient into an unconscious apneic patient who needs to be emergently intubated.
There is nothing wrong with doing RSI and DL for an emergency but I am not sure that it would be wise to turn an urgent situation into an emergency then treat it as such.
Nice case anyway.

 

[pgg]

Trach anyone?

I wouldn't RSI him. I would expect an awake FOI to be very difficult given the bloody airway, smushed facial bones +/- mandible fracture. The Lefort precludes a blind nasal approach for me. Maybe a gentle awake look with a Glidescope first ...

But in this short fat dude who had a difficult airway even before his face got crunched and his airway got bloodied, I have a hard time coming up with a reason to not do an awake trach from the start.

Besides, it gives you an excuse to shave the ridiculous ZZ Top beard.

 

[BLADEMDA]

Trach anyone?

I wouldn't RSI him. I would expect an awake FOI to be very difficult given the bloody airway, smushed facial bones +/- mandible fracture. The Lefort precludes a blind nasal approach for me. Maybe a gentle awake look with a Glidescope first ...

But in this short fat dude who had a difficult airway even before his face got crunched and his airway got bloodied, I have a hard time coming up with a reason to not do an awake trach from the start.

Besides, it gives you an excuse to shave the ridiculous ZZ Top beard.

The trach set-up was ready in the room along with the surgeon. Second, why do you all keep missing the point he was intubated at my institution previously? Third, if he was an "emergency" intubation in the E.R. the vast majority of Anesthesiologists would RSI him as shown by the study posted above.

I do like PGG's approach of taking a look with the Glidescope sans muscle relaxant. Just remember the majority of aspirations occur due to inadequate anesthetic and/or muscle relaxants. So, aspiration is a risk after PGG gives him 70-80 mg of Propofol for a "quick look."
Too bad JPP isn't around to chime in here.

 

[ssmallz]

trach anyone?

I wouldn't rsi him. I would expect an awake foi to be very difficult given the bloody airway, smushed facial bones +/- mandible fracture. The lefort precludes a blind nasal approach for me. Maybe a gentle awake look with a glidescope first ...

But in this short fat dude who had a difficult airway even before his face got crunched and his airway got bloodied, i have a hard time coming up with a reason to not do an awake trach from the start.

Besides, it gives you an excuse to shave the ridiculous zz top beard.

qft +1, sorry blade gotta agree w/plank on this one, no reason to RSI this guy as a first option

 

[BLADEMDA]

qft +1, sorry blade gotta agree w/plank on this one, no reason to RSI this guy as a first option

Do it every day slim. Just do what you are good at and do it well.

 

[BLADEMDA]

Quote:
Originally Posted by BLADEMDA

What about intraoperative monitoring and the patient's hypovolemia? Does everyone concur with Amyl?
Any concern with AIP?

Does his EF of 35% alter your plan in anyway? If so, how?

Blood bank just sent you 2 units of 0+ emergency release blood. They haven't got type specific blood but patient tells you he is AB-. Are you going to give the emergency blood or wait for AB-?


So, I put the arterial line in. Takes 35 seconds. ABG comes back with the following: 7.29/34/146 BE-14 Hemoglobin now 7.7

Careful induction with Propofol, 200 ug phenylephrine and Sux. Miller Blade and RSI (if it works). Cervical immobilization. Posterior Collar left in place. 8.0 et tube placed on first attempt. ETCO2, BBS.

Now, what about the ABG and the hemoglobin?


How about a Resident/Fellow giving his/her answer? (Plank let them post before you chime in).

 

[BLADEMDA]

Anesth Analg. 2009 Sep;109(3):866-72.
The success of emergency endotracheal intubation in trauma patients: a 10-year experience at a major adult trauma referral center.

Stephens CT, Kahntroff S, Dutton RP.
Division of Trauma Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
Abstract

BACKGROUND: Emergency airway management is a required skill for many anesthesiologists. We studied 10 yr of experience at a Level 1 trauma center to determine the outcomes of tracheal intubation attempts within the first 24 h of admission. METHODS: We examined Trauma Registry, quality management, and billing system records from July 1996 to June 2006 to determine the number of patients requiring intubation within 1 h of hospital arrival and to estimate the number requiring intubation with the first 24 h. We reviewed the medical record of each patient in either cohort who underwent a surgical airway access procedure (tracheotomy or cricothyrotomy) to determine the presenting characteristics of the patients and the reason they could not be orally or nasally intubated. RESULTS: All intubation attempts were supervised by an anesthesiologist experienced in trauma patient care. Rapid sequence intubation with direct laryngoscopy was the standard approach throughout the study period. During the first hour after admission, 6088 patients required intubation, of whom 21 (0.3%) received a surgical airway. During the first 24 h, 10 more patients, for a total of 31, received a surgical airway, during approximately 32,000 attempts (0.1%). Unanticipated difficult upper airway anatomy was the leading reason for a surgical airway. Four of the 31 patients died of their injuries but none as the result of failed intubation. CONCLUSIONS: In the hands of experienced anesthesiologists, rapid sequence intubation followed by direct laryngoscopy is a remarkably effective approach to emergency airway management. An algorithm designed around this approach can achieve very high levels of success.

This patient was intubated within the first hour of arriving in the E.R. Hence, the data from the well controlled study above validates RSI as a reasonable approach to trauma patients. However, if you lack the experience or skill, or are just uncomfortable with a particular airway, an awake intubation can be a prudent approach.

As we can see for this case discussion there are a wide range of opinions. However, please note surgical airway back-up was immediately available along with Glidescope and LMAs.

Blade

 

[pgg]

Second, why do you all keep missing the point he was intubated at my institution previously?

I'm not really reassured by his prior easy intubation given that it probably wasn't urgent or complicated by blood, facial fractures, or c-spine precautions.

Your points on aspiration in inadequately anesthetized or relaxed patients are well taken though. And on second thought I'm less enthusiastic about an awake look given his questionable c-spine.

 

[BLADEMDA]

I'm not really reassured by his prior easy intubation given that it probably wasn't urgent or complicated by blood, facial fractures, or c-spine precautions.

Your points on aspiration in inadequately anesthetized or relaxed patients are well taken though. And on second thought I'm less enthusiastic about an awake look given his questionable c-spine.

This isn't my first rodeo. I am well aware of all the risks to this patient. From Cricothyrotomy to Aspiration to Failure to Intubate I have been there and done it. I fully respect a reasonable approach when it is your ass on the line provided you have Plan B and hopefully C ready to go. I doubt a young Attending would fail his Oral Boards because he chose my plan. I certainly wouldn't fail him provided he had Plan B and C. With blood in his mouth an awake FOI will be a difficult approach in my seasoned hands. I much prefer the Miller 2/3 blade and/or the Glidescope.

 

[Licoricestick]

The trach set-up was ready in the room along with the surgeon. Second, why do you all keep missing the point he was intubated at my institution previously? Third, if he was an "emergency" intubation in the E.R. the vast majority of Anesthesiologists would RSI him as shown by the study posted above.

We're not (although that wasn't made clear in your early posts), but the fact is that you've told us that his airway has CHANGED since his CABG (which was 9yrs ago anyway). You can now no longer manipulate his neck and he potentially has blood in his airway. FM ventilation may now be more difficult (esp if he has put on weight since his CABG). To rely on the fact that he was intubated 9yrs ago at the same hospital, but not by you, is taking a significant risk.

 

[Idiopathic]

im glad to know im not insane; i was putting this guy to sleep from the get go. who wants to be messing with a bloody fiberoptic intubation in what should be an obtainable airway...it seems as though everyone is fixated on FOI for the neck injury but try keeping a patient still through a difficult FOI - i think good inline stabilization and a video laryngoscope after induction of anesthesia is my mode of securing this airway 99 times out of 100.