actual clincal thread

[bostonblaz]

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interesting case that happened this past week

i am currently on an intensive care rotation and get paged to the bedside of trauma/mi. 66 y/o male mvc vs tree with c4 fracture in collar as well as nasal fractures that are packed with profuse bleeding. the ed as well as card and surg teams felt he did not need a tube in the ed and was rushed to the cath lab( i forgot to mention he had chest pain and the cause of his accident turned out to be an mi). while in the cath lab he has two episodes of vtach/fib and was not intubated at that time, stents placed and he is sent to csru. i get paged b/c the anesthesia team on call in the or is busy. i get called b/c his bp in begining to drop as well as his sats. on my quick exam he is big in a collar and when he opens his mouth there is copious amounts of blood...what would you do???

 

[Tenesma]

call surgery team to bedside for preparation of bedside trach.

get your difficult intubation cart to the bedside

and start doing a differential

1) is this because of a pneumothorax - get CXR

2) is he desatting cause he is bleeding into his lung?

3) is he desatting cause he ain't perfusing his lungs because of right heart failure??? (what territory was the mi?)....

etc..etc...

but you need to secure the airway and HIGH likelihood of just having to go for the trach at the bedside....

my initial thought would be to determine if you could do an awake fiberoptic with tons of SUCTION through his mouth

or wait until he decompensates and becomes unresponsive and turn it into a real flogging ---- even better, page the MEDICAL code team to the ICU (that always made for a good laugh when the fleas show up and can't figure out what to do with a rapidly decompensating patient...)

 

[huktonfonix]

glidescope, retrograde intubation, cricothyroidotomy, trach. And like tenesma said figure out whats going on.

 

[Fah-Q]

interesting case that happened this past week

i am currently on an intensive care rotation and get paged to the bedside of trauma/mi. 66 y/o male mvc vs tree with c4 fracture in collar as well as nasal fractures that are packed with profuse bleeding. the ed as well as card and surg teams felt he did not need a tube in the ed and was rushed to the cath lab( i forgot to mention he had chest pain and the cause of his accident turned out to be an mi). while in the cath lab he has two episodes of vtach/fib and was not intubated at that time, stents placed and he is sent to csru. i get paged b/c the anesthesia team on call in the or is busy. i get called b/c his bp in begining to drop as well as his sats. on my quick exam he is big in a collar and when he opens his mouth there is copious amounts of blood...what would you do???

Whoever made the decision to send this guy to the cath lab without a secure airway forgot the golden rule...A-B-C. You don't get a C4 fracture and just "nasal fractures." I'd be willing to bet this guy had a full-blown NOE fracture, and they can bleed like stink. If the bleeding was bad enough to need packing and he needs cervical spine immobilization then you have to secure the airway. If he bleeds through the packs (which it sounds like he did) then you are f'ed.

He should have been electively intubated or trached. Now that he is bleeding and in trouble you don't have a choice anymore. Call ENT STAT for a slash trach.

 

[coprolalia]

i get called b/c his bp in begining to drop as well as his sats.

Spinal shock.

Suction oropharynx. Small amount of etomidate. No relaxation. Blind oropharyngeal intubation (not nasal with the fractures) using an Endotrol with a BAAM attached to it. Try it. You like it. And, you'll look like a complete stud.

-copro

 

[bostonblaz]

all good ideas, i got the cart, got a second pair of hands, tried 1st attempt with 4%lido on the oral airway and fiberoptic with no sedation..absolute blood bath in the oropharnyx but could see bubbling. sats now 88, decide to push etomidate 10 sux 100 and shoot for the bubbles, get in on second attempt(only pushed drugs after surg at bedside on standby with scalple).looking back on it i probably would have opted to sedate but if it were not for the breathing i would not have been able to bubbles and i would not know where to place the tube, i am going to check up on him tonight and i will give you guys some follow up.

 

[Planktonmd]

all good ideas, i got the cart, got a second pair of hands, tried 1st attempt with 4%lido on the oral airway and fiberoptic with no sedation..absolute blood bath in the oropharnyx but could see bubbling. sats now 88, decide to push etomidate 10 sux 100 and shoot for the bubbles, get in on second attempt(only pushed drugs after surg at bedside on standby with scalple).looking back on it i probably would have opted to sedate but if it were not for the breathing i would not have been able to bubbles and i would not know where to place the tube, i am going to check up on him tonight and i will give you guys some follow up.

There is really no right answer here.
I am curious though: You said you gave Etomidate + Sux and went for the bubbles, do patients continue bubbling after you give them Sux?

 

[Noyac]

Nice job. I'll just give my 2 approaches but as you know the only thing that matters is that you get the tube in.

1st approach is to take a look with a MAC4 blade with the sats low and him decompensating. Probably not going to see much.

2nd and my favorite approach, is to place a fasttrack LMA in and start to ventilate him. This will not extend his unstable neck and will hopefully keep the blood out of the cords so you can ventilate him. If it seats well, I'd put him to sleep if I didn't already for the LMA placement. Most likely he would have fought some and I would have had to put him to sleep for the placement. Once I am comfortable with ventilation I'd try to intubate through the LMA. FOB or blindly.

I have done many unstable necks this way with the pts crashing. The Glidescope is a nice tool but not in this situation (blood in the airway). Plus the LMA allows you to ventilate the pt.

 

[Tenesma]

here is a good trick

if you paralyze somebody with tons of blood in oropharynx and you no longer see the bubbles, then have somebody forcefully do a chest compression and an abdominal compression at the same time and that should pop open the cords and push out some air and allow you to aim for the bubbles...

however that trick will only work 2 or 3 times (in my experience) because after that there ain't much air left.....

 

[Noyac]

here is a good trick

if you paralyze somebody with tons of blood in oropharynx and you no longer see the bubbles, then have somebody forcefully do a chest compression and an abdominal compression at the same time and that should pop open the cords and push out some air and allow you to aim for the bubbles...

however that trick will only work 2 or 3 times (in my experience) because after that there ain't much air left.....

Where did you learn that one?

I mentioned the same thing right here on this site about a year or so ago. It works for sure. 👍

 

[Tenesma]

I learned it the hard way - a dead cystic fibrosis kid who they called a code on - i was trying to intubate this poor guy with mucus and stomach contents in the pharynx that kept welling up despite suctioning - and when they started to do chest compressions etc i "found" the cords/trachea/bubbles...