What were the circumstances? And how was it managed? Curious to hear everyone's experiences.
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.
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.
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
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.
The real question is whether or not you cut the post-carotid neck open yourself while waiting for the surgeon.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.
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.
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?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?
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.
I'm curious how many people demonstrate ability to mask before giving paralytics.
I'm curious how many people demonstrate ability to mask before giving paralytics.
I'm curious how many people demonstrate ability to mask before giving paralytics.
I'm curious how many people demonstrate ability to mask before giving paralytics.
Almost never. Exceptions are things like the rare inhalation induction, burn-no-bridges approach to, say, a mediastinal mass.I'm curious how many people demonstrate ability to mask before giving paralytics.
Thx. Also curious if a HELP/rev t/or ramp was used. How obese was she?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.
Has anyone been burned by NOT demonstrating ability (attempting) to mask b4 paralytics?
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?