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bloody airway
Started by anes121508
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I read this thread a few days ago at 3pm just before going in for my ICU night float shift.
Ironically, a couple hours into the shift I was stat paged to a patients room who became acutely short of breath. The Pt was a middle age female with end stage AML s/p allograft with GVHD and Sepsis. She had thrombocytopenia with plts < 15 for days. On arriving to the room her HR was in 30's and she was pulseless. We started compressions for PEA and coded for ~ 10 mins. CRNA shows up to intubate. I was running code so he took the airway. He takes over bagmask, suctions copious blood from mouth, passes ETT. No etCO2 but do hear rochurous bilateral breath sounds, but very high pressures required to ventilate. We suction tube no avail. No air in abdomen he swears it was through the cords. He removes ett and reintubate with same issue. I take a look (CA-2 resident) and see bloody jumbled mess. All I see now is epiglottis. I shove suction deep below epiglottis and pull out a HUGE blood clot the size of golf ball directly from trachea. Pass ett and get etCO2 and breath sounds. Pt makes quick recovery hemodynamically shortly thereafter (+/- multiple bolus's epi/vaso/atropine and epi gtt). She did have tension pneumothorax after the fact that resolved with quick placement of chest tube.
I will say it was a tough decision to remove an ett that seemed to be in the right place. In hindsight the Pt was having intermittent nose bleed and likely developed a huge clot in naso/oropharynx that was aspirated into trachea. Im pretty sure the ett was through cords on all intubations.
Any other way to manage this situation without removing ett? Fiberoptic was not immediately available, but im sure that clot would not have made it through the ett. I must say I was SERIOUSLY doubting the decision to remove ett when I initially took a look and saw such a mess. I was thinking that she was not going to make it and we would have 10 minutes of documented DL with no ett in trachea (on autopsy). I will go ahead and say that the blind suction of this huge clot was complete luck/blessing as I was pretty convinced that the situation was not going to end well just before this happened.
Ironically, a couple hours into the shift I was stat paged to a patients room who became acutely short of breath. The Pt was a middle age female with end stage AML s/p allograft with GVHD and Sepsis. She had thrombocytopenia with plts < 15 for days. On arriving to the room her HR was in 30's and she was pulseless. We started compressions for PEA and coded for ~ 10 mins. CRNA shows up to intubate. I was running code so he took the airway. He takes over bagmask, suctions copious blood from mouth, passes ETT. No etCO2 but do hear rochurous bilateral breath sounds, but very high pressures required to ventilate. We suction tube no avail. No air in abdomen he swears it was through the cords. He removes ett and reintubate with same issue. I take a look (CA-2 resident) and see bloody jumbled mess. All I see now is epiglottis. I shove suction deep below epiglottis and pull out a HUGE blood clot the size of golf ball directly from trachea. Pass ett and get etCO2 and breath sounds. Pt makes quick recovery hemodynamically shortly thereafter (+/- multiple bolus's epi/vaso/atropine and epi gtt). She did have tension pneumothorax after the fact that resolved with quick placement of chest tube.
I will say it was a tough decision to remove an ett that seemed to be in the right place. In hindsight the Pt was having intermittent nose bleed and likely developed a huge clot in naso/oropharynx that was aspirated into trachea. Im pretty sure the ett was through cords on all intubations.
Any other way to manage this situation without removing ett? Fiberoptic was not immediately available, but im sure that clot would not have made it through the ett. I must say I was SERIOUSLY doubting the decision to remove ett when I initially took a look and saw such a mess. I was thinking that she was not going to make it and we would have 10 minutes of documented DL with no ett in trachea (on autopsy). I will go ahead and say that the blind suction of this huge clot was complete luck/blessing as I was pretty convinced that the situation was not going to end well just before this happened.
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You should have intubated the first time. Even if you are "running" the code.
Toughest decision there is. This is an oral boards stem if ever there was one. No real right answer, but some definite wrong ones.
1) Assume tube is in the trachea. Almost all your differentials here involve resistance to flow (either bloodflow - huge MI/PE, or airflow - tube/tracheal occlusion or severe bronchospasm). Troubleshoot those as best as you can, sounds like you did that.
2) Pull the tube early rather than late if easy airway (or dont...CPR doesnt HAVE to have an ETT...dont waste time with an airway if you are the only one there, and dont get caught up in it if you need to be running a code - with that said, you can do an easy airway AND simultaneously run a code)
3) Ive always thought that I would try a bronch in this situation, but there wont be time, and unless you yourself see it going through the cords, you wont believe its there...sometimes you have to do it yourself (ive learned this in the OR - pulled a perfectly good tracheal tube out and replaced it 2/2 bronchspasm).
In general terms yes, but if the patient codes from hypoxia then you better fix the tube.
D
deleted59964
anyone use high dose roc, with sugammadex as your reversal plan?
It's nice to have in case you RSI with roc, but it's been available for something like 2 years now and i've never used it.
I have heard the company has renewed interest in trying to get past the FDA. New research protocols coming down the pike. At best, prob still 2 years away I suspect.
D
deleted59964
oh - i didn't realise that - have used it a lot here but haven't had to reverse high dose roc with it yet.
?! 😕
If you're at the head of the bed with a blade and a tube in your hand...you ain't running the code. Those are mutually exclusive. I think it's reasonable to entrust laryngoscopy and intubation to a CRNA during a code.
While I don't feel inclined to address every one of your many patently ridiculous claims...
We do this all the time in the US. For elective surgical cases. On healthy patients. Oh yes. Oh yes, we do.
One technique I favor is lidocaine 1-2mg/kg plus propofol 2-3mg/kg plus alfentanil 30-40mcg/kg or remifentanil 2-4mcg/kg. In my N = 15 or so, jaw loose and VC open every time.
I'd have to agree. Let the team members do their jobs and you do yours. You might think "oh I'll just pop the tube in and get back to work, but what happens if the airway turns out to be difficult? Then you're screwing around trying to get that resolved. Then maybe the access team member can't get an IV/central line, so then you volunteer to help with that.
So who's running the code while you're doing those things? I wouldn't go so far as to NEVER step outside your role. Maybe it's an intern trying to secure the airway, and they clearly don't know what they're doing. But in the scenario presented, there's a trained anesthesia provider who presumably should be able to handle an airway.
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You mean the one (yes n=1) that patients who are intubated (and not in cardiac arrest) should be paralysed first rather than just knocked down a couple of pegs so they accept the tube?
Fascinating, I'm not sure if it makes us unique for not doing it or you unique for doing it; much like the whole rest of the world using the metric system and the US not.
You might do things differently but it is certainly at odds to accepted practice elsewhere in the world; in fact the practice of just knocking people down to intubate them was withdrawn here for concerns it was actually doing more harm than good.
But heck you charge people for health care too so ....
From his post, he was in the ICU at bedside some time before the crna got there. I probably have run many more codes than both of you combined but there really isn't anything to it. The tube is what was going to save this patients life. Whoever was bagging should have noticed the lake of blood in the patients mouth and a tube should have been expeditiously placed. It's a PEA code in the ICU. The patient has access already. There is nothing to do inititially besides epi, compressions, tube which should have happened immediately.
Yeah, it's such a pain to figure out how many drams of propofol to give when they package the damn stuff in ounces. But since all Americans weigh at least 20 stone, a whole pint is usually needed to knock them down anyway, so most of us just skip the math altogether.
Besides, everybody holds still after a few pennyweights of
🙂
Just to once again point out, there appears to be a time period in between the patient arriving in ICU and having a PEA arrest. I'm not advocating anaesthetising and paralysing a PEA arrest patient.
And yes I know what a Quarter Pounder is, but I much prefer a Double Whopper with Cheese or a Double Double Double Double Double Double from In N Out
And yes I know what a Quarter Pounder is, but I much prefer a Double Whopper with Cheese or a Double Double Double Double Double Double from In N Out
im not sure if you guys are arguing the same case, at this point. two have been presented.
just remember the case scenario with the aspirated peanut and what to do when all of a sudden you cant ventilate - push it more distally. if you have a tube through the cords and you saw it go through and you cant ventilate, then you need to probably consider bilateral needle decompression and flushing the airway with saline flushes until you can get something like a scope to see whats going on.
My point is, you can't do everything in a code ("run" it, airway, access), even though you might be the best at each individual thing. We all know you're a badass and for some reason intubated/ran a zillion codes as an intern (what the hell is going on at your hospital anyway?)
Must be at MmacFN's CRNA-only hospital, where they reportedly exclusively take care of ASA 4 and 5s all day long.
Lots of discussion around this point and I have to agree with those who favor the code-runner keeping hands off the patient. As an intensivist who has attending hundreds of codes, both real and simulated (we have an active sim research and training enterprise), I have to point out that the dynamic changes completely when the code-runner starts assisting procedures. (this comes up a lot when our sims start out as a non-code emergency, like an RRT call, but turn into codes; it's really hard for people to step back and take in the whole picture once someone codes).
Of course, we can all concoct a scenario where the pharmacist shows up drunk, or the airway person gets blinded by an errant whatever, and the code leader may be the only other person able to address the fallen member's task, but in general, efficiency, organization, and thoroughness take a serious nose-dive when the code-leader stops leading the code and starts touching the patient.
My point is about the time interval. Instead of someone doing ineffective bag mask ventilation through an oropharynx filled with blood (10 minutes of this according to his post!) and waiting until the CRNA arrived, it should have been done much sooner.
The hospital where we do our internship is a very large, very busy hospital. Lots of transplants, LVADs, and sick as hell renal patients. Even worked on 2 patients with mechanical hearts. Not zillions of codes, I had just over 40. Probably only had help, be that resident or attending, on 5 of those.
The hospital where we do our internship is a very large, very busy hospital. Lots of transplants, LVADs, and sick as hell renal patients. Even worked on 2 patients with mechanical hearts. Not zillions of codes, I had just over 40. Probably only had help, be that resident or attending, on 5 of those.
You're saying a bunch of words just to say them. I don't know if it's your New Zealandish accent or what but I cannot understand a one word you're saying.
This happens in microcosm quite frequently in gnarly traumas, ruptured AAAs, etc, in the OR, where an attending is directing a team of people, like anesthesia personnel, circulators, etc.
Once that team leader starts laying hands on the patient -- drawing up drugs, helping with access, etc -- things get crazy and all the team members start running around in circles, miscommunicating or not communicating at all.
Communication with all team members present and assessment of the global situation is the team leader's real job...not DL/ETT.
