Airway case from the weekend

[pgg]

So I figure I ought to at least occasionally post something that isn't firearm or politics related ...


The setting is a small community hospital where I occasionally cover weekend call from home. About 1 AM the ER calls me and says they have a 65 year old female patient who transferred from an even more podunkville ER with a neck mass who is stridorous and struggling to breathe. Apparently they'd spoken with ENT (who was also on home call) and he'd asked that the patient be evaluated by anesthesia before he made the 25 minute drive in.


So I go in to see her. Turns out the neck mass is a supraglottic airway tumor for which she's been followed elsewhere. An elective trach had been recommended to her but she refused. As part of her workup a neck CT had been done the previous week. The radiologist's impression is available but the images aren't. The fax says she has a 3 cm supraglottic mass with airway narrowing to 2 mm at one point. Normal anatomy below the cords. The CT stopped before they made it to the chest because she couldn't tolerate being flat in the tube.

Other medical history from chart fragments, family members, and the patient (who can't speak and is so exhausted from breathing that she doesn't want to write notes)

• Denies coronary disease but ECG shows Qs in inferior leads and ST depression in V4-6 (one set of enzymes from other ER are negative). Takes atenolol for HTN.
• Lung tumor of unknown type, size, stage, mets. Denies COPD - no MDI use.
• Seizure disorder on Dilantin, but no seizures for many months.
• Hypothyroidism - presently euthyroid on Synthroid.
• Throughout her life multiple uncomplicated general anesthetics for various procedures

Vitals
- HR 110s
- BP 190s / 120s
- RR ... well, chest heaving at about 30/min, but stridorous gasps at maybe 6-10/min
- SpO2 low 90s with frequent trips to the low 80s, getting racemic epi by facemask now

Exam
- Sitting bolt upright, exhausted, disheveled, anxious/terrified, retractions & accessory muscle use. She does not want to lay flat.
- MP 3, dentures.
- Short but thin neck. Not that I was eager to cut it, but it looked as doable as any neck ever does.
- Stridorous. Lungs coarse, she needs to cough up some gunk but can't.

Labs
- ABG at 10:00 PM at the other ER was 7.35 / 57 / 70 / 32 on room air
- ABG at 12:55 AM here was 7.22 / 74 / 78 / 31 on 10 liters facemask with reservoir
- Chemistry: Na 123, K 3.1, Cl 84, CO2 31, BUN 5, Cr 0.5
- INR 1.0

Except for the ER, ICU, and ward nursing stations, the hospital is dark and no one is home. Someone asks me if I'm going to intubate her now. They have the vent ready and everything, how much etomidate do I want?

Curious to hear how others would proceed. I'll post what I did later.

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[Noyac]

Put the tube in and go back to bed. What's the problem?

 

[Planktonmd]

She needs a tracheostomy or at least a cricothyroidotomy, if she is competent enough and continues to refuse these life saving procedures, then accommodate her wishes: send her to the floor on a morphine drip and go back to bed.

 

[G0S2]

In my intern mind (3 weeks from CA1 year!!) I don't see how you could avoid doing a cricothyroidotomy. She's starting to circle fast. I mean you can wait until she crumps and then do it or explain what you are going to do, snow her and put it in fast. And call that ENT dude b/c I bet he could get there in 15 min.

 

[urge]

pent, sux, botched tube, trach.

I guess you could try to fiberoptic, but why? She needs a trach anyway.

 

[Coastie]

Trach: a chance to cut is a chance to heal.

So I figure I ought to at least occasionally post something that isn't firearm or politics related ...


The setting is a small community hospital where I occasionally cover weekend call from home. About 1 AM the ER calls me and says they have a 65 year old female patient who transferred from an even more podunkville ER with a neck mass who is stridorous and struggling to breathe. Apparently they'd spoken with ENT (who was also on home call) and he'd asked that the patient be evaluated by anesthesia before he made the 25 minute drive in.


So I go in to see her. Turns out the neck mass is a supraglottic airway tumor for which she's been followed elsewhere. An elective trach had been recommended to her but she refused. As part of her workup a neck CT had been done the previous week. The radiologist's impression is available but the images aren't. The fax says she has a 3 cm supraglottic mass with airway narrowing to 2 mm at one point. Normal anatomy below the cords. The CT stopped before they made it to the chest because she couldn't tolerate being flat in the tube.

Other medical history from chart fragments, family members, and the patient (who can't speak and is so exhausted from breathing that she doesn't want to write notes)

• Denies coronary disease but ECG shows Qs in inferior leads and ST depression in V4-6 (one set of enzymes from other ER are negative). Takes atenolol for HTN.
• Lung tumor of unknown type, size, stage, mets. Denies COPD - no MDI use.
• Seizure disorder on Dilantin, but no seizures for many months.
• Hypothyroidism - presently euthyroid on Synthroid.
• Throughout her life multiple uncomplicated general anesthetics for various procedures

Vitals
- HR 110s
- BP 190s / 120s
- RR ... well, chest heaving at about 30/min, but stridorous gasps at maybe 6-10/min
- SpO2 low 90s with frequent trips to the low 80s, getting racemic epi by facemask now

Exam
- Sitting bolt upright, exhausted, disheveled, anxious/terrified, retractions & accessory muscle use. She does not want to lay flat.
- MP 3, dentures.
- Short but thin neck. Not that I was eager to cut it, but it looked as doable as any neck ever does.
- Stridorous. Lungs coarse, she needs to cough up some gunk but can't.

Labs
- ABG at 10:00 PM at the other ER was 7.35 / 57 / 70 / 32 on room air
- ABG at 12:55 AM here was 7.22 / 74 / 78 / 31 on 10 liters facemask with reservoir
- Chemistry: Na 123, K 3.1, Cl 84, CO2 31, BUN 5, Cr 0.5
- INR 1.0

Except for the ER, ICU, and ward nursing stations, the hospital is dark and no one is home. Someone asks me if I'm going to intubate her now. They have the vent ready and everything, how much etomidate do I want?

Curious to hear how others would proceed. I'll post what I did later.

 

[gaspasser2004]

In this case, the definitive treatment is a tracheostomy which should be done awake. Ideally, the ENT should do the trach and you should provide sedation with dexmedetomidine and "okay anesthesia" ("Ma'am, its going to be okay"). I would not want to approach the airway from above given the circumstances described.

I think the judgement call is whether or not you can wait for the ENT. If the ENT is truly only 25 minutes away, it would probably be reasonable to move the patient to the OR and start prepping and draping so that the ENT can cut as soon as he/she got there (or, alternatively, you could step in if need be). While you are waiting for the ENT to arrive, you can lower the blood pressure and heart rate which will hopefully make those ST depressions go away.

I think the ENT has put you in a pretty bad position. I see the ENT's concern that he/she doesn't want to drive 25 minutes in the middle of the night for nothing. However, the other side of that coin is that if things turn truly emergent, 25 minutes is way too far away.

 

[dhb]

14G to the cricothyroid membrane, try some CPAP while you wait for the ENT to put a steel blade to the throat.
If an elective trach was advised there's no reason why she wouldn't need an emergency one.

 

[doctor712]

Curiosity Qs:

so, what do you give to handle pain control in an awake trach?
local? sedative (for nerves) + local? in truth, what's the pain reality here?
does lidocaine do the job alone, and by do the job, i don't just mean finish the job, i mean,
allow for the patient to go through this without (at least dulled) sensation they are getting throat sliced...? (just a curious point here). you do what you have to do to make sure she lives.

so, she's already declined a trach once, let's say she keeps declining and tells you to F-off, "nobody is going to cut a hole in my throat when i'm awake..." and let's assume she has CAPACITY...then what? What would the GA plan be with this mass if she won't permit a trach?
Or rather, how would the GA plan differ in this patient from a healthy patient of her age and CAD history?

Would you fight her and could you say that this is emergent enough to pull the emergent card to do the awake trach regardless? (could you say that even with ENT sitting on his butt 25 mins away?) Would you feel comfortable saying that if she decides to file suit. In other words, are your emergent hands tied because ENT, who called you, is home?

So, now you have an awake, angry woman who is going to fight you with her hands, feet, because she doesn't want a trach and you decide you need to save her life... Is it tie down time? HEAVY sedation time? Would that heavy sedation cause further respiratory problems, and if so, how to balance her fighting you vs. breathing? Would it ever get that far, i.e. moment hole is cut, put her to sleep and nighty night time.

I guess I'm wondering, would you EVER consider putting her to sleep (moments) BEFORE doing the trach, you're going to cut anyway and I assume (oh boy) you would feel that you could ventilate distal to the mass, isn't that the point? I guess it might be VERY DEADLY to EVER make that assumption. I was once told that you do nothing until you can make sure the patient will ventilate...

Would love some real world thoughts. I'm hung up on an awake trach, but I understand the reason, from a pre-meds' POV anyway. I'll get over it.

Inquisitively,
D712

 

[hoyden]

Wait until ENT comes ( should hit the door by now) and together with him outline the future to the patient - it is either - or.

 

[pgg]

pent, sux, botched tube, trach.

Excellent ...



Despite the ER doc conveying the above story to ENT before I was called, ENT wanted 'more information' before making the trip. It seemed pretty clear just looking at her that she needed a surgical airway, but I felt stuck. ENT wasn't coming without 'more information' and neither I nor the ER doc wanted to do a cric in the trauma bay. So what to do ...


The first thing I did was stop the racemic epi and give some esmolol to get her HR and BP down.

Then, with the benefit of a brief spray of benzocaine and no sedation to avoid burning bridges, I took a look with a fiberoptic scope, thinking (hoping) an awake FOI might be possible. To the side of this chunk of broccoli growing out of her oropharynx I could get a glimpse of one of her vocal cords, which looked normal. While there I was able to suction out a bunch of secretions she hadn't been able to clear, and her breathing actually improved a little. Not much, but she intermittently saw the mid 90s again.

For a few moments I thought I might be able to drive the scope past the mass and intubate her awake but I decided not to push it. I wasn't going to do SLN blocks or transtracheal lidocaine with her distorted anatomy. I was also worried that even a couple of gentle unsuccessful passes would anger the mass or her airway and cause bleeding or swelling. And then I'd be doing a cric.

So I quit while I was ahead and called ENT myself this time. After I explained the futility of trying to get her intubated from above, he agreed to come in. We got to the OR about 30 minutes later.

She didn't like being less than vertical. Supine was out of the question so we settled for something around 45 degrees, which still made her uncomfortable and agitated. Dexmedetomidine would've been my first choice, but it wasn't available. Verbal reassurance was insufficient and even after a ton of local had been injected, she thrashed when he started working. I gave her 0.5 mg of midazolam followed a couple minutes later with 20 mg of ketamine ... which turned out to be plenty, because even though her respiratory drive remained intact, she obstructed completely at that point. From then on I was jaw-thrusting under the drapes to keep her upper airway open. The rest of it was uneventful. Trach done, sats up, HR/BP/RR down, to the ICU.


The main reason I posted this case is because I didn't handle it especially well. It'd be easy to post an interesting/tough case I knocked out of the park, but it's harder to hold my screwups out for everyone to see. Everybody here recognized right off that this patient needed a surgical airway. Not a whole lot of ambiguity there. Trach was the obvious correct thing to do from the start, and I knew it. Like dhb said, this is someone who'd been previously advised to get an elective trach well before this day came - she's not going to magically NOT need one at a later stage.

Scoping her was a mistake and I'm lucky I didn't make things worse by stirring up a bunch of blood and edema or delaying the trip to the OR. I don't know why ENT blew off the ER doc, but I should've called him myself first and insisted that he haul ass to meet us in the OR. Instead I let another doctor's reluctance to come in at 1 AM push me to do something I knew probably wasn't going to work.

Anyway, live & learn.

 

[hoyden]

double??

 

[Johnisit1234]

totally agree with the awake trach. i would agree with gaspasser2004 -- get her to the OR, and hopefully by the time that you're getting prepped, ENT can be there. be ready with a 14g as noted to jet ventilate if nothing else.

you could always hurricane spray the throat and try an awake glidescope and see if a small ETT will pass. regardless, ENT needs to be come in....

 

[pgg]

so, what do you give to handle pain control in an awake trach?

Local is usually enough. Presumably anyone getting an awake trach has some upper airway issue going on. A patient who can keep his airway open and breathe spontaneously with his own negative inspiratory force may not be ventilatable by us with positive pressure, so sedation, induction, and paralysis all carry the risk of creating an apneic patient we can't ventilate. Since these patients carry the added danger of difficult intubation, too much hypno juice or paralytic can push you into a can't intubate / can't ventilate corner.

So awake trachs usually get done with plenty of local, encouraging words, and minimal sedation.

so, she's already declined a trach once, let's say she keeps declining and tells you to F-off,

I neglected to mention in my OP that she was now consenting to a trach 'as a last resort' ...

Competent adults decline to consent to lifesaving treatment all the time, whether it's CPR, intubation, surgery, chemotherapy, etc; it's their right to choose to finish life free of our tubes, needles, and drugs. It would not have been unreasonable at all for this patient with lung CA and a laryngeal tumor to be DNR. If that was the case they'd never have called me in the first place.

Not respecting a competent adult's advance directive is bad.

I guess I'm wondering, would you EVER consider putting her to sleep (moments) BEFORE doing the trach, you're going to cut anyway and I assume (oh boy) you would feel that you could ventilate distal to the mass, isn't that the point? I guess it might be VERY DEADLY to EVER make that assumption. I was once told that you do nothing until you can make sure the patient will ventilate...

Every time you sedate, induce, or paralyze any patient you're betting their life on your ability to ventilate them.

Also, be sure you understand the distinction between a
1) cricothyrotomy - an emergency procedure that takes seconds and isn't intended to be the definitive airway. Generally for blue patients who are satting in the 60s and dying right now. Every one I've ever seen has been a messy cluster**** and they end badly as often as they end well.
2) tracheostomy - usually not truly emergent, requires deeper dissection through structures like the thyroid isthmus, takes minutes at best for a surgeon to do, intended to be the definitive airway. 'Emergency' trachs are probably better described as urgent - they're for patients who might die Real Soon Now and are (hopefully) more controlled procedures.


Tracheostomies are more often done in patients who are already intubated. That's usually an easy case because they start with a secured airway, though there's sometimes a tense moment when you pull the endotracheal tube back so they can slip the trach in. Solid anesthesia and paralysis are pretty much standard.

Most other trachs are more elective and don't have impending respiratory failure to contend with. An example is a person with a neck mass who's in for a scheduled neck dissection - 1st order of business is often a trach, and it's done in a very controlled manner. They're not hypoxic/hypercarbic/ischemic, so plenty of local and some reassurance with judicious sedation makes it a generally safe, controlled, not too traumatic experience.

And then there are trachs like the one in my case - a distressed patient who needs a surgical airway, but not so urgent that stabbing the cricothyroid membrane with an 11 blade and shoving a tube through it is warranted.

 

[fastosprintini]

nice and thoughtful post pgg!
i think you did great as the pt. is alive, the details fall by the side...
the ent painted you in a corner with his /her hesitation to come i right away, this might be reviewed by somebody else in the hospital.
in my opinion, if there is time to wait, wait for ent in the or, if there is no time ( the patient crumps in front of you) give a drop of ketamine or dex , localize with buffered lidocaine and do a awake cric right there in the er, consider that there is nothing to lose , or is there? it might not be the best as the patient needs a trach but so what , again, the pt is dead if you don't do it...!
my$0.02 , fasto

 

[IlDestriero]

Sounds like the ENT needs a punch in the gut, hard. They're the airway expert. This is a head and neck cancer patient for Christ's sake. He wants YOU to come in and eval the airway?
WTF!
THEY call YOU to come in to the OR for the urgent trach. I would have told the ED MD to have the ENT call you. Then tell him to F*ck off, you'll meet him, and the patient, in the OR. Seriously bad care. (not yours!)
The ER MD knew that the patient was obviously in distress, the need for a trach in this patient won't get any better when you are there holding his hand. The cancer is only going to get worse! The ENT probably was hoping that you would kill her in the ER so he wouldn't have to risk it in the OR.
On 2nd thought, he needs a punch in the mouth. Unbelievable.
You did a great job. They took advantage of you, or tried to. The guy who is probably helping out the anesthesia department tremendously with your moonlighting!
I will elect not to comment on the ED's use of epi in the patient having ischemia, with the vitals noted above. The problem is not a little edema, its a big F'ing airway tumor.

 

[doctor712]

Actually, that's a COUPLE of nice posts PGG, thanks for taking the time to explain!!! Really appreciate it.

Didn't know diffs between cric and trach.

Interesting case re: ethics too as I just finished biomed ethics. Cool course.

D712

 

[gaspasser2004]

Nice post pgg. Its easy for us Monday morning quarterbacks to say "surgical airway" from the comfort of our offices, but it is an entirely different thing to be there in the ED with a live patient and stubborn ENT doc who doesn't want to get out of bed. I think you handled the case reasonably and didn't burn any bridges with your gentle awake FOB. This is a good case for all of us to learn from.

 

[pd4emergence]

great case, thx for posting.

Would anybody here preemptively transtracheal jet ventilate this pt? Just wondering if anybody does this in pp (I haven't and probably would not here). I had an attending in residency who would have used this approach, ensured egress and then put this patient to sleep.

 

[Arch Guillotti]

The main reason I posted this case is because I didn't handle it especially well. It'd be easy to post an interesting/tough case I knocked out of the park, but it's harder to hold my screwups out for everyone to see. Everybody here recognized right off that this patient needed a surgical airway. Not a whole lot of ambiguity there. Trach was the obvious correct thing to do from the start, and I knew it. Like dhb said, this is someone who'd been previously advised to get an elective trach well before this day came - she's not going to magically NOT need one at a later stage.

Scoping her was a mistake and I'm lucky I didn't make things worse by stirring up a bunch of blood and edema or delaying the trip to the OR. I don't know why ENT blew off the ER doc, but I should've called him myself first and insisted that he haul ass to meet us in the OR. Instead I let another doctor's reluctance to come in at 1 AM push me to do something I knew probably wasn't going to work.

Anyway, live & learn.

This is nonsense to think that you didn't handle this case well. You took the bull by the horns and told the ENT to get his ass in there in the meanwhile you did what you could to stabilize the patient without causing any harm.

I think you did a great job.

In the right patient all an awake trach needs is local.

In the wrong patient things get a lot more difficult.

One thing (20/20 hindsight sort of thing) is placing an angiocath in the neck preemptively (for later cutting or jetting if it is available).

 

[SleepIsGood]

Nice post PGG. Can't blame anything you did--> great outcome.

Could you have tried an awake glidescope? Aerosilze lido , but a 6.0 tube in...I've done this before. As long as you aersolize lido sufficiently and wait....it's actually pretty smooth.

IN this case the luxury to wait for the ENT existed.....If she remained in the 80s and was going down....would you have considered an awake glide vs awake FOI.

 

[Arch Guillotti]

I think that putting a glidescope in the mouth is asking for trouble.

 

[Arch Guillotti]

She didn't like being less than vertical. Supine was out of the question so we settled for something around 45 degrees, which still made her uncomfortable and agitated. Dexmedetomidine would've been my first choice, but it wasn't available. Verbal reassurance was insufficient and even after a ton of local had been injected, she thrashed when he started working. I gave her 0.5 mg of midazolam followed a couple minutes later with 20 mg of ketamine ... which turned out to be plenty, because even though her respiratory drive remained intact, she obstructed completely at that point. From then on I was jaw-thrusting under the drapes to keep her upper airway open. The rest of it was uneventful. Trach done, sats up, HR/BP/RR down, to the ICU.

This is THE proverbial rock and a hard place. I kind of think you dodged a bullet here. Ketamine is great but it is not the end all be all. In someone like this you can easily obstruct and completely lose the airway.

 

[pgg]

Would anybody here preemptively transtracheal jet ventilate this pt?

One thing (20/20 hindsight sort of thing) is placing an angiocath in the neck preemptively (for later cutting or jetting if it is available).

I entertained the possibility of transtracheal lidocaine for further attempts at awake FOI but I decided sticking a needle in the neck with altered anatomy was risky. It probably would've been OK though since she had good external landmarks and the CT report said the mass was supraglottic.

Honestly never thought of doing a pre-emptive angiocath for jet ventilation.

Sounds like the ENT needs a punch in the gut, hard.

In the ENT's defense, I don't know what kind of picture the ER doc painted for him. I don't know why he didn't come in first. I didn't ask. When I finally did call him, he didn't hem/haw or anything ... just said he'd be right there. And he was pleasant, fast, and skilled.

I'm inclined to give him the benefit of the doubt. I bet if I'd called him immediately after I first saw the patient he'd have come in.

Could you have tried an awake glidescope? Aerosilze lido , but a 6.0 tube in...I've done this before. As long as you aersolize lido sufficiently and wait....it's actually pretty smooth.

IN this case the luxury to wait for the ENT existed.....If she remained in the 80s and was going down....would you have considered an awake glide vs awake FOI.

We have McGrath video laryngoscope not a Glidescope there. I considered an awake look with it briefly but decided against it. I didn't want to DL her with anything because the CT said the mass was immediately supraglottic, and my guess was that any rigid hard thing placed around the epiglottis risked stirring up a huge mess of blood and friable tumor.

I forgot to post that when I dumped the racemic epi on the floor I replaced it with some 2% lidocaine to supplement my benzocaine spray. Couldn't find any 4% which is what I usually use for nebulized lidocaine. I do like it for awake FOIs but using the 4% nebs + transtracheal + pledgets etc adds up the total lidocaine dose quickly.

McGrath was my plan B if things went to hell during my fiberoptic look to be rapidly followed by a cric as plan C.

 

[pgg]

I will elect not to comment on the ED's use of epi in the patient having ischemia, with the vitals noted above. The problem is not a little edema, its a big F'ing airway tumor.

Yeah. There's that.


On another note, this was my 2nd patient in as many days who came in with SIADH from a lung mass. Interesting sideline ...

 

[RT2MD]

great case, thx for posting.

Would anybody here preemptively transtracheal jet ventilate this pt? Just wondering if anybody does this in pp (I haven't and probably would not here). I had an attending in residency who would have used this approach, ensured egress and then put this patient to sleep.

pgg,
Great case, I loved reading about it. I am a frequent lurker on here and really enjoy the topics that are discussed. I can't wait for this journey called medical school to start!

pd4emergence,
I noticed that pgg said that he was in a small community hospital (maybe located in BFE?). Me thinks that the likely hood of having a jet ventilator around is slim... Maybe I'm wrong here. I guess having an angio cath in place could at least let you hook some O2 tubing up to it (not sure how)? I dunno, just my thoughts.

Thanks for sharing!

 

[Arch Guillotti]

Jet ventilation may not be a feasible option (especially in an ED) however a preeemptive angiocath might still be useful (wire into trachea, cut, dilate, goof around, definitive airway).

 

[pgg]

I noticed that pgg said that he was in a small community hospital (maybe located in BFE?). Me thinks that the likely hood of having a jet ventilator around is slim... Maybe I'm wrong here. I guess having an angio cath in place could at least let you hook some O2 tubing up to it (not sure how)? I dunno, just my thoughts.

We have jet ventilators on all the anesthesia machines, and there was one in the ER.

Hooking up O2 tubing to it won't work. Jet ventilators get fed directly from the ~50 psi wall O2. O2 tubing coming off a tank regulator or wall regulator doesn't have the oomph to get much through an angiocath, even a 14g one.

Also, part of the mechanism for jet ventilation is entrainment of room air via the Venturi effect so in addition to sufficient volume going through the angiocath, it has to be moving at a sufficient velocity. You really can't give effective breaths through an angiocath via regulated wall/tank O2 or an ambubag.

 

[TwilightDoc01]

We have McGrath video laryngoscope not a Glidescope there. I considered an awake look with it briefly but decided against it. I didn't want to DL her with anything because the CT said the mass was immediately supraglottic, and my guess was that any rigid hard thing placed around the epiglottis risked stirring up a huge mess of blood and friable tumor.
.

Great case and great job on the mgt.

I'm not familiar with the McGrath, like Sleep we have Glidescopes only. It seems the principles for bth are similar. While I can see how you dont want to 'stir up' stuff .....when you insert the Glidescope or McGrath you can watch the screen as you advance the videolarynscope. If you see a mass and suspect it's friable, you can back off without touching it with the laryngoscope.

I just think videolaryngoscope witha Glidescope/McGrath gives a better view/feel for what's really going on. As long as you nebulize with lido really well, and suction and a little benzocaine, I've seen these too be very smooth.

Great case! Glad the patient did well.

 

[pgg]

This is THE proverbial rock and a hard place. I kind of think you dodged a bullet here. Ketamine is great but it is not the end all be all. In someone like this you can easily obstruct and completely lose the airway.

Yes - I was not expecting to get burned by 20 mg of ketamine like that. Was grateful that a simple jaw thrust kept her open.

 

[pd4emergence]

pgg,
Great case, I loved reading about it. I am a frequent lurker on here and really enjoy the topics that are discussed. I can't wait for this journey called medical school to start!

pd4emergence,
I noticed that pgg said that he was in a small community hospital (maybe located in BFE?). Me thinks that the likely hood of having a jet ventilator around is slim... Maybe I'm wrong here. I guess having an angio cath in place could at least let you hook some O2 tubing up to it (not sure how)? I dunno, just my thoughts.

Thanks for sharing!

Most places have jets (at least the places I have worked).

 

[Planktonmd]

Jet ventilation is a viable solution and it would buy you time but this patient had previously refused a tracheostomy so maybe she is smarter than all of us and wants us to leave her alone.
Sometimes people deserve the dignity of dying on their own terms.

 

[pd4emergence]

Jet ventilation may not be a feasible option (especially in an ED) however a preeemptive angiocath might still be useful (wire into trachea, cut, dilate, goof around, definitive airway).

I think you could jet (if available) but only if there was no other choice and the ENT guy was not there yet.

Here is what we would do (with a particular attending) in residency. Lidocaine skin, long 16g angiocath with syringe with saline, bubbles, angiocath placed, cvl wire through angiocath, angiocath out, vessel dilator from 7fr cvl kit in, wire out, reaspirate with syringe(make sure to get air), jet hooked up to dilator (dilator more rigid and works better with the jet). Then this particular attending would check for egress, if it was there he would induce and the ent's would do the trach. This guy made it work and did it routinely. Interesting and fun to do as a resident, this would be scary as hell to do as an attending.

 

[Fah-Q]

I do 3-4 trachs per week and deal with a lot of head and neck cancer. Here are my thoughts:

One other option to think about to "temporize" an obstructing patient is Heliox. It may not have been available in this little hospital but all you guys at the Big U would have access to it. It would have been perfect in this lady because you had to turn off the racemic epi.

I wouldn't stick anything in the airway with a known tumor unless you have everything ready to go for a surgical airway if you cause big time bleeding or a tumor chunk breaks off and obstructs the patient. I've seen this happen firsthand and I had to slash and burn.

Your ENT owes you a beer for sure.

 

[Jay K]

The fax says she has a 3 cm supraglottic mass with airway narrowing to 2 mm at one point. Normal anatomy below the cords.

PGG - Great post and excellent job; I applaud your sharing of this very useful teaching case despite your thinking you could have done things better/differently. I know we always hear of the cases that are batted as home runs, but if you had omitted this case, I would have personally missed out on learning something and having a case scenario under my belt for when/if this ever hits my door.

As an aside, despite other questions about attempts to intubate, it's the 2mm narrowing on CT that would have prevented me from attempting a supraglottic approach to instrumenting the airway; What kinda tube you gonna pass from above that's got a diameter that will be useful? I also agree I wouldn't want to mess with a friable tumor mass in an already compromised patient.

Here is what we would do (with a particular attending) in residency. Lidocaine skin, long 16g angiocath with syringe with saline, bubbles, angiocath placed, cvl wire through angiocath, angiocath out, vessel dilator from 7fr cvl kit in, wire out, reaspirate with syringe(make sure to get air), jet hooked up to dilator (dilator more rigid and works better with the jet). Then this particular attending would check for egress, if it was there he would induce and the ent's would do the trach.

pd4emergence: Very nice technique - thanks for sharing. I can visualize it very well and the availability of a CVL kit to facilitate this process makes it very handy.

 

[pgg]

As an aside, despite other questions about attempts to intubate, it's the 2mm narrowing on CT that would have prevented me from attempting a supraglottic approach to instrumenting the airway; What kinda tube you gonna pass from above that's got a diameter that will be useful? I also agree I wouldn't want to mess with a friable tumor mass in an already compromised patient.

Well, 2 mm as measured by CT doesn't mean that space will only accomodate a 2 mm tube. Right now my mouth is closed and a CT would show a 0 mm space, but it's certainly big enough to accept a foot once in a while.

As it turned out I got a partial view of her vocal cords through more than 2 mm of space. Many times I've looked at CTs of ICU patients and seen little or no space around the ETT but they extubated easily. I'm never sure quite what to make of lumen measurements on CT. One more red flag of concern, sure ... as for the absolute accuracy of the measurements, I don't know.

 

[radiodoc99]

Interesting case.

 

[drccw]

Nice case... the ED doc dropped the ball by not getting the ENT to come in sooner.. the only error in the case is the time for the ENT to come in...

I've stuck the neck before, transtracheals etc... I would be hard pressed to stick the neck here. It's easy to say she needs a surgical airway- and that's what the ENT is there for.. in a crump, maybe I would use the Ez cric kits we have but it doesnt sound that this lady is in dire straits... I would be cautious with trans tracheal jet ventilation... It can only temporize a situation, but it can definitely definitely make things worse.. All those stories about subcutaneous emphysema are definitely true...

drccw

 

[doctor712]

Naive question:

I know anesthesia are the masters of airway, but WHY doesn't the EM-trained MD do the surgical airway him/herself? Would they do this themselves if this were a Level I trauma center? Does it have to be crump through the door for them to do this?

D712

 

[Intensivist]

why would ER doc do trach on patient that's not crashing in front of him/her? it's ENT job to do elective surgical trachs.

But on the other hand, how many of you do percutaneous trachs, regardless of settings, ICU mostly...

 

[doctor712]

Point taken, but if she NEEDS a surgical airway (and an anesthesiologist ends up taking the case and doing so) and this is due to obstruction, is this still "elective"??? Elective as in, I'd like to breathe and remain conscious into the foreseeable future?

If it's ENT's job and not ERs job to take care of this patient because she wasn't "actively dying quickly" than now I see why all are saying ENT should have gotten out of bed ASAP. Hope I never have that guy as my ENT...

Thanks again for replies PGG.

D712

 

[SexPanther]

Had an incredibly similar case a couple of calls ago - called stat "anesthesia only" overhead to the ED. When I hear that I'm thinking extreme badness....either something they have made really messy or something so bad they call us straight up.

When I arrived (with a lot of help in tow), I came into a trauma bay with a lady with a large supraglottic tumor (by report) sitting bolt upright, receiving racemic epi and satting in low 80s. Do everything possible.

Trauma surgeon standing by with the blue rhino kit open. After we made sure he was good to go, we had had them stop the racemic epi cuz it was only making her extremely tachycardic, told her "This may feel uncomfortable" as we threw in nasal airways dripping with 4% viscous lidocaine and then hit her with benzocaine spray to the oropharynx.

Went to attempt a awake oral fiberoptic, but was not impressed with benzocaine's abilities. Maybe I didn't apply it properly, but she was having none of it as soon as the scope neared the posterior oropharynx.

We abandoned that approach and proceeded to spray some lidocaine via an atomizer. This, combined with the lidocaine that had since dripped down the naso and oropharynx gave us good working conditions.

Thus, we were able to perform an awake nasal fiberoptic intubation around a nasty looking mass and pt. was shipped off to the MICU.

That was a really scary thing for sure. We may have just got lucky, but having back-up in the form of someone who can wield the scalpel was key.

 

[RT2MD]

We have jet ventilators on all the anesthesia machines, and there was one in the ER.

Hooking up O2 tubing to it won't work. Jet ventilators get fed directly from the ~50 psi wall O2. O2 tubing coming off a tank regulator or wall regulator doesn't have the oomph to get much through an angiocath, even a 14g one.

Also, part of the mechanism for jet ventilation is entrainment of room air via the Venturi effect so in addition to sufficient volume going through the angiocath, it has to be moving at a sufficient velocity. You really can't give effective breaths through an angiocath via regulated wall/tank O2 or an ambubag.

Cool, thanks for letting me know. I'm not overly experienced with the jet ventilators, I don't think that we use them at all where I work (at least outside of the OR we don't). It does make sense about having to come directly off the 50PSI outlet, though. I guess that resistance would be through the roof with that small of a radius.

As an aspiring Anesthesiologist, I sure do enjoy reading through threads like this! Thanks again!

 

[Hamhock]

I have read the discussions of potential awake intubation on this patient with great interest, especially the different techniques for delivering lidocaine; never actually considered dripping viscous down a NPA (cool idea)...but there is no mention of glycopyrrolate.

Do any of you guys pre-treat with a little glycopyrrolate, if you have time?...with the idea of decreasing secretions, making your topical more effective and you visualization better.

Why? Why not?

Lurker from the EM world,
HH

 

[pgg]

Glycopyrrolate is nice for a planned awake FOI. It's less useful at reducing secretions if securing the airway is more urgent because it takes time to work.

It also increases HR which, although controllable with more esmolol, would've been undesirable in this patient.

 

[proman]

I have read the discussions of potential awake intubation on this patient with great interest, especially the different techniques for delivering lidocaine; never actually considered dripping viscous down a NPA (cool idea)...but there is no mention of glycopyrrolate.

Do any of you guys pre-treat with a little glycopyrrolate, if you have time?...with the idea of decreasing secretions, making your topical more effective and you visualization better.

Why? Why not?

Lurker from the EM world,
HH

I like using diphenhydramine when there's time. It's mildly sedating but does dry secretions without tachycardia but you need about 5 minutes for it to work. I hope you aren't thinking of doing fiberoptic intubation personally. I would be concerned with most emergency physicians attempting fiberoptic intubation. Especially in a patient like this it should be performed by specialists who routinely do it and are accustomed to difficult airways (ie anesthesiologists and otolaryngologists). Knowing when to ask for help is probably the most important step of the difficult airway algorithm.

 

[Arcan57]

ED doc should not have hung up with ENT until the words "I'll be there in x minutes" were said. In regards to crics, there is significant morbidity associated with them and it obviously wouldn't replace the (longterm) need for a trach in this patient. Also, there are probably very few physicians who have any substantial experience with cricothyrotomy. Most of the trauma surgeons I've worked with would do a quick and dirty trach versus a cric. None of my attendings in residency (at a shop that managed ~1800 airways/yr) had done more than a couple. All of which contributes to making a crich a last ditch procedure.

As a question, is there a specific reason that anesthesiology does not train for trachs and crics? I understand the need for them with all of the tools and the extensive training is pretty low, but it seems that it could be a valuable addition to the toolkit in emergencies.

 

[sevoflurane]

ED doc should not have hung up with ENT until the words "I'll be there in x minutes" were said. In regards to crics, there is significant morbidity associated with them and it obviously wouldn't replace the (longterm) need for a trach in this patient. Also, there are probably very few physicians who have any substantial experience with cricothyrotomy. Most of the trauma surgeons I've worked with would do a quick and dirty trach versus a cric. None of my attendings in residency (at a shop that managed ~1800 airways/yr) had done more than a couple. All of which contributes to making a crich a last ditch procedure.

As a question, is there a specific reason that anesthesiology does not train for trachs and crics? I understand the need for them with all of the tools and the extensive training is pretty low, but it seems that it could be a valuable addition to the toolkit in emergencies.

Yes we do train for both. Usually on pigs. Did a couple trachs during my surgery rotations but under guidance and controlled conditions. Emergency trachs are another beast all together. Usually there is some sort of surgeon around who has more experience than one of us in doing them. If you start doing a trach or cric for whatever reason, you better know what you are doing.

Who manages the AW while you are doing a trach? This is the question.

Reminds me of an ICU code where a 350 lb dude had his ATV roll over him and mess up his face (and many other systems) pretty bad . Looked like angioedema on steroids. Well... he has strong enough to pull his tube out. I got there and struggled to keep his sats in the mid 70's. Bagged him with 2 hands and barely was ventilating, but I was squeaking in some O2.
Took the surgeon 15 minutes to get through his thick neck... No way I was about to do a trach on that guy. It's like letting a surgeon do a known difficult AW. Got to know your limits.

Bagging that guy was a good workout BTW. Forearms and hands had some pretty good levels of lactic acid circulating.

 

[Arch Guillotti]

As a question, is there a specific reason that anesthesiology does not train for trachs and crics? I understand the need for them with all of the tools and the extensive training is pretty low, but it seems that it could be a valuable addition to the toolkit in emergencies.

I did not specifically train for a trach during residency, although I certainly got "stuck" with my fair share of trachs. I scrubbed in for a few as a medical student but none as a resident. I did enough transtracheal blocks during residency to feel good about about them so that if I ever had to emergently jet or cut someones neck I could maintain a semblance of an airway based on my familiarity with landmarks.

 

[Arcan57]

Yes we do train for both. Usually on pigs. Did a couple trachs during my surgery rotations but under guidance and controlled conditions. Emergency trachs are another beast all together. Usually there is some sort of surgeon around who has more experience than one of us in doing them. If you start doing a trach or cric for whatever reason, you better know what you are doing.

Who manages the AW while you are doing a trach? This is the question.

Reminds me of an ICU code where a 350 lb dude had his ATV roll over him and mess up his face (and many other systems) pretty bad . Looked like angioedema on steroids. Well... he has strong enough to pull his tube out. I got there and struggled to keep his sats in the mid 70's. Bagged him with 2 hands and barely was ventilating, but I was squeaking in some O2.
Took the surgeon 15 minutes to get through his thick neck... No way I was about to do a trach on that guy. It's like letting a surgeon do a known difficult AW. Got to know your limits.

Bagging that guy was a good workout BTW. Forearms and hands had some pretty good levels of lactic acid circulating.

Wouldn't ever attempt a trach, would do a cric if that was the only option left on the failed airway algorithm. If I'm having to do a cric, there's probably going to be an RT (or possibly another EP) attempting to ventilate while I cut.

Definitely agree with the value of bagging, something I think almost all non-anesthesiologists suck at (including myself). Looking back, that should have been the skill I tried to master during my anesthesia rotation.