For the case-deprived:
1. Called to SICU electively. 45 year old stocky male s/p trauma, complete C6-7 cord injury the previous day. In c-spine traction and c-collar. T/L spine injuries as well. No movement BLE, some movement BUE and very anxious, tearful, complaining of burning pain in LUE. h/o sleep apnea, reflux. MP3, large tongue, good mouth opening, TM>3fingers. 116/67 on phenylephrine gtt, HR 96. Increasing tachypnea and O2 requirement, SICU requests intubation under controlled daytime circumstances. Next? (Information gathering/preparation, airway plans A/B/C/D, drugs...)
2. Called to the SICU at 6pm. 350lb male s/p trauma 5 hours ago. Came to ED with ortho injuries, hypotensive, altered mental status. Attempted intubation by ED docs in ED gone vastly awry with massive vomiting and suspected aspiration, emergent cric performed in trauma bay by trauma service with 6.0 ETT currently stenting said cric. Difficult to ventilate- peak pressures in 40s, ABG PCO2= >100 (VBG PCO2 on arrival, lying flat on his back before intubation = 68). Trauma attendings feel swapping out for an oral, bigger tube will solve their problems. Next?
1. My oral board answer would be awake fiber optic, sound like you have time. He is getting worse, but not emergent, yet. If he's not cooperative, then you could wheel him to the OR, have all of your goodies (FOB, glidescope, intubating and non-intubating LMAs, and a second set of hands) ready, and an ENT or gen/trauma surgeon with a trach tray hanging out watching. Gas him down, and take a look while he's still breathing. Start with your device of choice change as appropriate, hopefully you won't need to change.
If this is an urgent/emergent, then glidescope is a great way to go, and would probably be my real life answer. I think, for c-spines the glide scope is the best view for the least traumatic way of obtaining. FOI might be less traumatic, but no guarantees on a good view.
The next question is paralysis (to facilitate intubation that is). This is HD1, then sux all the way for his RSI. If this is HD5-7 or beyond, then I would switch to roc.
Finally, he's in clearly in spinal shock. I really like to stay away from etomidate if I can, especially in him as I would presume he's getting a whole lot of methylpred, don't go hatin' on the adrenals. I might go with a couple mg of midaz then a baby dose of propofol. I might mix me up some 10 mcg/ml epi to have for my induction. I have an attending who I have seen mix up his "propolphenylephrine". Add a couple 100 mcg of neo to your induction (small dose) stick of propofol, not my choice but something to consider. I would like it if they chose norepi instead of neo, but either is probably fine. I realize that his hypotension is mostly secondary to no squeeze from absent sympathetic tone, but he's probably out some cardiac innervation as well, and if you want to keep things perfused why not hit from both ends, crank up the pump and clamp him down.
2. Yikes. Well, a couple ways to skin this cat. Big picture, bird in hand beats two in bush. Don't lose the airway you have until you have something better. Clearly something has to change, but this doesn't sound emergent, yet. Good point brought up about the vent management, not my thing (yet), but hopefully next year I'll have more to offer. I presume those causes have been worked out, optimize I:E, flows, watch for auto-peep, and sedation. Is he really fighting the vent? Doesn't take much for 350 pounder to get the pips to 40 if he's bucking a lot.
The next thing that no one mentioned yet is does he have a PTX? A tension ptx could create this situation (it's happened to me) I'm guessing not, but if he does then he needs a chest tube first. So, get a fresh cxr, not the five hour ago one, a new one. This will also tell you if he's mainstemmed. Less likely with this scenario, but much easier to fix then changing tubes.
So, once all of those non-change the tube things are ironed out, and you decide he needs a tube how do you do it. First thing I would do, get him sedated. Next, get out your spaghetti noodle FOB. Take a peek. I wouldn't be looking to confirm placement, between the cxr and the fact he's not dead five hours later I'm guessing its okay, but to see if something else is in the way causing your problem, emergent cric there could be a hunk of cartilage obstructing, or the tube could be kinking on the back of trachea. If there is a big ole mucous plug you'll find out as well, although you probably can't suction through the FOB you're putting in a 6.0 tube. If all of that is pristine, no kinks, no snot I would then give him 50 of roc and do a DL, again making sure that he's sedated.
Happy with the view? Here's the plan, put the vent on 100% to preoxygenate. Get a tube exchange stylet, if you have one that has a lumen for oxygenation then use that one, but I don't think they make them small enough to fit through a tube that small. A gum elastic bougie will due if that's all you have. Gently advance it through cric tube. Now, DL again with an oral tube in hand, at least a 7.5 this time. Once you are just about through cords have an able assistant remove the tube and leave the stylet behind. Advance the oral tube just past cords, inflate and check. If you see it or hear through the cric hole (I think its funnier to it a hole rather than stoma) pull the stylet and advance the tube below cric, bring up the cuff and you're in business.
Not happy with the view, or think that plan is too bold. Here's plan B, you might need three people to help, an decent RT could probably be one of them. Get a FOB and load it up with at least a 7.5 tube. Advance a stylet through the cric tube as above. The third person might be need to place a laryngoscope to hold the tongue out of the way you can snake the FOB in a bit easier. Find the cords, drive through. Quickly check the cric hole from below. Advance the tube on the FOB just about to the end. Have your assistant remove the cric tube leaving the stylet behind. Now advance your tube the rest of the way. Note the distance at the teeth, see if things look good through the scope, pull the stylet, then pull the FOB. Now he's breathing easier.
Ultimately he may need a trach, but you don't really want to dilate his cric any more. I'm not an ENT, but there can be a lot of problem from crics. There's a reason that we do trachs for the long term. We like crics because with landmarks you can find a big membranous target in a hurry, instead of blindly fracturing tracheal rings as you railroad something through the trachea.
I had a real case like #2, and I had to deal with a lot of it solo. On call one night, code 199 called. Previously healthy gentleman who had been in house about two weeks since diagnosis of Guillain-Barré. Supportive care, semi elective intubation, nothing abnormal about his course. He is POD2 from tracheostomy. I get to the room, and its R3 me and some R3 medicine peeps I know from med school. CPR, asystole, a few rounds of epi. The RT has taken him off of the vent and his hand bagging him. She complains he's really hard to bag. I give him some roc, DL him, grade I view. Get an ET tube ready. Have the RT remove the trach sutures. I DL again, tube past cords, have her pull the trach, advance the tube. Push it down past the trach hole bring up the balloon, success, now he's easier to bag. Pulse comes back, massive hypertension from epi. Collective sigh. CXR taken. I'm brain storming with medicine peeps. My attending arrives. RT notes he's getting a little tougher to bag. Look at his chest and neck, extensive thick sub-q emphysema. My attending and I run to look at the CXR on the PACS terminal. PTX on the right. We come back, bradying, BP dropping. We grab the longest IV catheter we can find, too short can't make it through the all the sub q air, can't even get to bone. Somehow someone finds a spinal needle, I ram it in, grab a syringe start sucking air. Things arrive, and by this time surgeons arrive and place chest tubes.
Ultimately, after things settled down we found out he had been oozing blood from his trach. It collected in a large clot that obstructed his entire right main stem. I presume the clot fell into place caused a sudden complete right main stem obstruction than either one of two things happened. The pressure dislodged the trach, and resulted in a his arrest and then CPR caused his PTX. Or the pressured cause a tension PTX on the left and then the mix of sub-q air plus CPR and usual code things dislodged the trach. The ENT and the general surgeon spent the rest of the night picking the clot out piece by piece with the graspers from a FOB. The trach was revised a day or two later. The patient improved, weaned off the vent, and suffered no cognitive impairments. He went home. That case has made me reflect on how I would handle the same thing again. The only change I would have made is leaving something behind in the trach hole after pulling the trach. As a last resort you could at least attempt replace a similiar sized tube over the stylet. I didn't leave myself that out in my case, but it worked out. Okay, I've rambled enough.
