Who has had a cannot ventilate scenario?

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propadope

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What were the circumstances? And how was it managed? Curious to hear everyone's experiences.

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I've had massive facial trauma that required surgical cricothyrotomy. Vent was not attempted as the required structures for a mask seal, LMA, etc. were not in their proper places.
A colleague had a dramatic tonsillar bleed that presumably aspirated a large clot in the distal trachea with the expected drama. Suction and attempted intubation failed. That patient had a slash trach from ENT.
 
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Big fat guy in MICU, GI bleed--->MI--->cardiac arrest--->ETT dislodged during compressions by MICU team. Could not see anything on DL (prior to video laryngoscopes, though with all the blood that may have been worthless anyway), could not ventilate with bag or LMA. Did transtracheal 14g Jelco with jury-rigged jet ventilation (stopcock plus wall O2) until ENT arrived for slash trach. guy walked out of hospital.
 
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I've had massive facial trauma that required surgical cricothyrotomy. Vent was not attempted as the required structures for a mask seal, LMA, etc. were not in their proper places.
A colleague had a dramatic tonsillar bleed that presumably aspirated a large clot in the distal trachea with the expected drama. Suction and attempted intubation failed. That patient had a slash trach from ENT.

How did a trach solve the "clot in the distal trachea" problem?
 
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I personally have had only laryngospasm and stiff chest. Both treated with sux and the latter +narcan. Just wanted to get these two run of the mill stuff out of the way. So you can tell me about some crazy $&@#%
 
Both CA-1 year :cool:

1) pharyngeal/laryngeal SCC patient who shouldn't have been put to sleep. Mass had grown aggressively since last outpatient transnasal endoscopy. GA induced --> impossible mask, impossible glidescope --> trach. First time I saw a pulse ox at 3% with a good tracing.
2) burn ICU patient intubated x 7 days or so, having big debridement and grafting of posterior burns in prone position. Horrible mucous plugging and couldn't access ETT to suction properly in the Proneview. Lost etCO2 and ability to ventilate just as surgeon was finishing. Flipped supine and once able to suction ETT all was good.
 
About 3 months ago I got called to help an experienced attending and resident with a post carotid endarterectomy that was bleeding after extubation. The surgeon was freaking out. The patient was induced again and we could not intubate or ventilate. After two intubation attempts we were able to solve the problem with an LMA while the surgeon was fixing the carotid.
The patient got a teach immediately afterwards.

Looking back, maybe using ketamine and keeping the patient spontaneously breathing might have been the best option.
 
Pt brought emergently to OR POD#1 anterior cervical laminectomy for new onset neck swelling and stridor. Patient arrested in transport just before arriving to OR. I was called immediately to the OR. Compressions, immediately tried to intubate with glide, couldnt make out any structures past epiglottis. Tried to bag mask was a no go. Neck swollen making a cricothyrotomy attempt practically worthless. Popped in a #4 LMA got EtCO2. Pt had return of pulses, pulse ox>90% EtCO2 in 100's. Told surgeon he needs to cut before I lose airway again. Called trauma surgeon to bedside scrubbed with trach ready before cutting. Neurosurgeon evacuates hematoma, pop the glidescope in... Grade 1 view, pop ETT in. Patient walked out of the hospital within a week.

LMA saved his life.
 
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About 3 months ago I got called to help an experienced attending and resident with a post carotid endarterectomy that was bleeding after extubation. The surgeon was freaking out. The patient was induced again and we could not intubate or ventilate. After two intubation attempts we were able to solve the problem with an LMA while the surgeon was fixing the carotid.
The patient got a teach immediately afterwards.

Looking back, maybe using ketamine and keeping the patient spontaneously breathing might have been the best option.[/QUOTE




Carotid hematoma is scary. Maintain spontaneous ventilation if at all possible, even if it means some pain while surgeons decompress
 
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I've had 3 cases of being unable to ventilate-- all survived the problem. Stay calm and remember that Oxygenation takes priority so be prepared to do a needle cric if it is needed; once the saturation starts falling you have maybe 2-3 minutes until full cardiac arrest so your options are limited.

All my cases requiring needle cric or trach had the following:

1. Tumor obstructing cords (laryngospasm- Desat- needle Cric)

2. Large hematoma on neck compromising airway with glottic edema (FOI failed)

3. Misplaced Trach with lots of Subq Air (massive facial trauma so intubation or LMA not an option).

I can't stress the fact you must remain calm and do what is required to save the patient's life. All 3 of these patients left the hospital despite the bleak situation at the time.
 
About 3 months ago I got called to help an experienced attending and resident with a post carotid endarterectomy that was bleeding after extubation. The surgeon was freaking out. The patient was induced again and we could not intubate or ventilate. After two intubation attempts we were able to solve the problem with an LMA while the surgeon was fixing the carotid.
The patient got a teach immediately afterwards.

Looking back, maybe using ketamine and keeping the patient spontaneously breathing might have been the best option.

If the lma didn't work, the neck should immediately be decompressed with a scalpel to the sutures holding it in. And once the hematoma is evacuated and the bleeding is controlled, a trach is not always necessary.
 
If the lma didn't work, the neck should immediately be decompressed with a scalpel to the sutures holding it in. And once the hematoma is evacuated and the bleeding is controlled, a trach is not always necessary.
The real question is whether or not you cut the post-carotid neck open yourself while waiting for the surgeon.

Some people wouldn't. I said I would cut it open during a CA-1 mock oral, and my attendings/examiners shot me down. Added it to the tally of "two killed, one paralyzed" for the mock oral. :blackeye:
 
The real question is whether or not you cut the post-carotid neck open yourself while waiting for the surgeon.

Some people wouldn't. I said I would cut it open during a CA-1 mock oral, and my attendings/examiners shot me down. Added it to the tally of "two killed, one paralyzed" for the mock oral. :blackeye:

If the hematoma was large and impacting the airway to the point that intubation is difficult I would re-open the neck with the help of a certified surgical tech in the O.R. Fortunately, I can usually find a General Surgeon to assist me in a few minutes but if, for whatever reason, one was not available I would do what needs to be done. I've been involved with about 8-10 of these cases in my career so I feel comfortable enough with a small incision to drain the hematoma until the Vascular/CV surgeon arrives on the scene.

If the LMA works for you and buys the time needed for the surgeon to arrive and decompress the neck then by all means go that route. Typically, a good surgical tech and an experienced Board Certified Anesthesiologist are sufficient to deal with the situation until the surgeon arrives on the scene.
 
Tough situation. You also have to be prepared for the same expanding hematoma the reason that the pt doesn't exsanguinate. Opening a surgical wound without the necessary skills to repair a bleeding vessel could be lethal. I don't feel comfortable enough to open a potential carotid bleed, so I would do all supportive measures to keep the pt alive.
 
If it was a carotid gusher it'd have been apparent in the OR. These hematomas are slow leaks of a size that can get missed in the OR. He won't exsanguinate if you pop the sutures, but he might asphyxiate if you don't.

I know, I know, easy call from behind a keyboard. :) Here's hoping I never go there.
 
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Not that either of these are OR relevant: Probably the worst I ever had to deal with that survived was an asthmatic that used some bad cocaine. He had such a severe allergic reaction to it that no mode of ventilation would work- we're talking peak pressures of 60+ after only delivering 150cc of tidal volume- basically just ventilating dead space. Tried APRV, PCV, VCV, PRVC, HFOV, you name it. Eventually ended up manually bagging him myself for two hours while we tried everyrhing we could think of. As a last ditch effort, we figured we'd try dropping a small dose of epi down his ETT. Almost miraculously, it worked, and within an hour he was down to peak pressures of 40 with decent minute ventilation.

Worst that didn't live was a guy that developed a tracheoaortic fistula secondary to a recent aortic aneurysm repair. I've never seen so much blood in a non-trauma patient, it was literally spraying out of the exhalation valve of the bag. Started getting really frothy after a while, looked like sea foam made of blood. Anesthesia dropped a double lumen tube into the guy in the hopes that clots would only wreck one lung, but it was too late.

Plenty of nasty plugs which are easy enough, but I've dealt with them outside of the OR, no idea how you guys manage with someone on the table like that.
 
I have had a couple cant-ventilate cases.One was very early in my career, and this was resolved with an LMA followed by a fiber-optic intubation with the help of an aintree catheter.I had only read about the technique at that point, having never practiced it, but it worked beautifully.

I have encountered two other cases that I could neither ventilate nor intubate, and I performed cricothyrotomy on both. This seems like a good time to mention that neither of these started out as my case. The first was a code blue situation in a patient with a bleeding nasopharyngeal carcinoma. The second was someone else's case that I was called in to rescue. In the code blue situation, I started with the needle Seldinger technique, and quickly transitioned to using the knife from a triple lumen kit to complete the procedure. As others have mentioned in other threads, a great technique is a vertical incision followed by manual dissection followed by insertion of a small endotracheal tube directly through the crycothyroid memberane.

This procedure is a whole different animal compared to opening a surgical incision to drain a hematoma. I'm not sure I would have the balls to do that even though I am comfortable cutting the neck for a surgical airway.
 
I had a bad case of ACEI induced angioedema that was a cant ventilate situation and due to a series of blunders by the ER he couldn't be intubated. He got a slash trach in the ER bay by ENT and then it was cleaned up in the OR.
 
I had a bad case of ACEI induced angioedema that was a cant ventilate situation and due to a series of blunders by the ER he couldn't be intubated. He got a slash trach in the ER bay by ENT and then it was cleaned up in the OR.

I've had 2 cases of severe ACE inhibitor Angioedma as well. One got a glidescope which I was fortunate to get away with while the other got a FOI in the O.R. Even though I got away with the use of the Glidescope I'm less inclined to go that route again vs FOI.
 
I have had a couple cant-ventilate cases.One was very early in my career, and this was resolved with an LMA followed by a fiber-optic intubation with the help of an aintree catheter.I had only read about the technique at that point, having never practiced it, but it worked beautifully.

I have encountered two other cases that I could neither ventilate nor intubate, and I performed cricothyrotomy on both. This seems like a good time to mention that neither of these started out as my case. The first was a code blue situation in a patient with a bleeding nasopharyngeal carcinoma. The second was someone else's case that I was called in to rescue. In the code blue situation, I started with the needle Seldinger technique, and quickly transitioned to using the knife from a triple lumen kit to complete the procedure. As others have mentioned in other threads, a great technique is a vertical incision followed by manual dissection followed by insertion of a small endotracheal tube directly through the crycothyroid memberane.

This procedure is a whole different animal compared to opening a surgical incision to drain a hematoma. I'm not sure I would have the balls to do that even though I am comfortable cutting the neck for a surgical airway.
In your first case, what was the reason for the inability to ventilate? Did u go straight to LMA or attempt OPA/NPA/jaw thrust/two person. Was the mask fit and seal adequate? Pt obese? OSA? Signs or indicators of potential difficulty? Paralytics given?
 
Severe status asthmaticus...

Ended up futzing around for a couple hour with worsening hypercarbic resp. failure; then VV ECMO.
 
In your first case, what was the reason for the inability to ventilate? Did u go straight to LMA or attempt OPA/NPA/jaw thrust/two person. Was the mask fit and seal adequate? Pt obese? OSA? Signs or indicators of potential difficulty? Paralytics given?

Good questions. She was obese and had osa. The mask fit was good and I used an opa before trying the lma. It was in my first week as an attending and I was working with a brand new ca1; perhaps my own confidence was not very high and that contributed to jumping to the lma early. I had not given paralytics. My practice has evolved, but back then I didnT give paralytics until I had demonstrated mask ventilation.
 
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Good questions. She was obese and had osa. The mask fit was good and I used an opa before trying the lma. It was in my first week as an attending and I was working with a brand new ca1; perhaps my own confidence was not very high and that contributed to jumping to the lma early. I had not given paralytics. My practice has evolved, but back then I didnT give paralytics until I had demonstrated mask ventilation.

Awesome self-assessment.
 
Good questions. She was obese and had osa. The mask fit was good and I used an opa before trying the lma. It was in my first week as an attending and I was working with a brand new ca1; perhaps my own confidence was not very high and that contributed to jumping to the lma early. I had not given paralytics. My practice has evolved, but back then I didnT give paralytics until I had demonstrated mask ventilation.
Thx. Also curious if a HELP/rev t/or ramp was used. How obese was she?
 
Has anyone been burned by NOT demonstrating ability (attempting) to mask b4 paralytics?
 
Has anyone been burned by NOT demonstrating ability (attempting) to mask b4 paralytics?

Yes, once in residency when I wanted to AFOI the pt, but my attending thought the glidescope would be fine. Couldn't ventilate, couldn't see anything with the glide, got lucky blindly passing the tube down a hole that wasn't on the screen. Testing wouldn't have helped much in that situation (other than maybe the attending would have pushed sux, rather than roc), as we were essentially committed when we put her to sleep.
 
Big fat guy in MICU, GI bleed--->MI--->cardiac arrest--->ETT dislodged during compressions by MICU team. Could not see anything on DL (prior to video laryngoscopes, though with all the blood that may have been worthless anyway), could not ventilate with bag or LMA. Did transtracheal 14g Jelco with jury-rigged jet ventilation (stopcock plus wall O2) until ENT arrived for slash trach. guy walked out of hospital.

When advancing transtracheal with Jelco, how did you aspirate air/know when you were in the trachea?
 
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