C1 fracture and awake FOI

[92122]

Guy I know recently was confronted with a C1 fracture and elected to do an awake FOI with transtracheal and SLN blocks. After the tube was in, the patient, whose head was sandbagged and taped in place, was able to move all extremities on command. Induction proceeded and the anesthesiologist felt that he had safeguarded himself against lawsuits that might misconstrue a surgical (or any other non-anesthetic) complication with injury that occurred during intubation.

He was asked about a FOI or glide scope intubation asleep and paralyzed and he felt that his approach was superior because the patient demonstrated neurologic competence after intubation.

The possibility that the patient might cough due to transtracheal blockade placement or a less-than-perfect set up prior to FOI concerned some who heard about this scenario.

What say you?

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[caligas]

Assuming a decent airway it seems safer for the patient and easier for me to parylize and use glidescope or fiberoptic with collar in place.

 

[deleted126335]

This is one that reasonable people will disagree about.

The easier looking the airway, the more likely I am to go for a glide scope.

 

[Agast]

The possibility that the patient might cough due to transtracheal blockade placement or a less-than-perfect set up prior to FOI concerned some who heard about this scenario.

Meh. He could also cough at any time sitting in the ED because his throat is scratchy. Coughing is a natural human reflex. Someone flexing your head back (let's face it, in-line stabilization is never as stable as it should be) is not natural. I'd rather defend a cough than my buddy's hands not getting as good a grip as he should.

 

[pgg]

From your short description, I didn't get any indication that (absent the C1 fx) there was anything difficult or concerning about the airway, or reason to think that mask ventilation would be difficult.

Even the smoothest AFOI with the best topicalization risks a patient coughing or jerking or freaking out. Proper tracheal topicalization invariable produces coughing and movement all by itself. I don't think the dubious legal CYA benefit of a post-intubation neuro exam is at all worth that risk.

I don't think an AFOI in a patient with a c-spine injury but otherwise reassuring airway is something I would ever consider.

 

[fakin' the funk]

I don't think an AFOI in a patient with a c-spine injury but otherwise reassuring airway is something I would ever consider.

So...

Asleep airway manipulation, which involves movement of C1 100% of the time, is OK...

But coughing, which does not involve movement of C1, is to be avoided by the plague?!?!

I'm don't really see how someone with literally the most threatening possible spine fracture doesn't buy themself an AFOI.

 

[pgg]

Asleep airway manipulation, which involves movement of C1 100% of the time

Does it? Asleep intubation of an NMBD-paralyzed patient requires C1 movement 100% of the time? I'm not talking about DL, which does require a-o extension. Even though there's data that suggests that in-line stabilization is sufficient to avoid cord injury from DL, it's probably best not to go the DL route.

An asleep FOI, light wand, or Glidescope intubation in an immobile patient strikes me as far more controlled than an awake intubation. That's just my bias.

 

[jwk]

So...

Asleep airway manipulation, which involves movement of C1 100% of the time, is OK...

But coughing, which does not involve movement of C1, is to be avoided by the plague?!?!

I'm don't really see how someone with literally the most threatening possible spine fracture doesn't buy themself an AFOI.

I'm still trying to figure out why a neurologically intact patient with a C1 fracture is having surgery, with the significant risks of compromise from intubation and especially positioning. I thought the preferred route with these patients was application of a halo.

 

[Mman]

So...

Asleep airway manipulation, which involves movement of C1 100% of the time, is OK...

But coughing, which does not involve movement of C1, is to be avoided by the plague?!?!

I'm don't really see how someone with literally the most threatening possible spine fracture doesn't buy themself an AFOI.

I don't know how you intubate somebody with a glidescope, but it doesn't involve moving C1 when I do it. They only movement of their head is opening their jaw. That's it. If the surgeon is feeling nervous, I'll have them hold the head. There is less movement during intubation than there is when the surgeon positions the patient for the procedure. As to coughing and there not being movement at C1, you must be joking.

 

[Planktonmd]

Here is what I would do:
If the airway looks difficult (morbidly obese, short thick neck, history of difficult intubation...) then good topical anesthesia and transtracheal, whith the patient in rigid collar then followed by smooth awake fiberoptic intubation.
If the airway looks good then asleep fiberoptic intubation in collar as well.
In my hands a fiberoptic intubation is way slicker and less traumatic than any other video laryngoscopy device you might want to use, but I realize that this might not be the case for everybody.

 

[ASA6]

I don't know how you intubate somebody with a glidescope, but it doesn't involve moving C1 when I do it. They only movement of their head is opening their jaw. That's it.

These arent the best studies, but they show that you do more moving at c1 than you think. In fact, the first study shows decreased movement at c2-5 with the glidescope compared to the mac blade, but the same degree of movement at c1. I think coughing is also probably not that great either. These studies do show minimal c-spine movement with mask ventilation. With this limited knowledge, I would choose to induce anesthesia and muscle relaxation, and do an asleep fiberoptic.

http://www.anesthesia-analgesia.org/content/101/3/910.long

http://journals.lww.com/ejanaesthes...l_spine_movement_during_endotracheal.951.aspx

 

[pd4emergence]

A few questions
1. Do you really get no movement at c1 with an awake foi? Even a very smooth one.
2. Does a small amount of movement with a careful intubation (regardless of how you do it) really matter?

Lots of literature out there that supports doing an asleep technique in this patient. Also lots of practicing anesthesiologists that would absolutely say that you have to do an awake foi in this situation. Personally, given that there are no other complicating factors, I would sleep the patient and use the glidescope to get a view, then use the fiber scope as a drivable stylet to get the tube in with as little cervical movement as possible.

 

[92122]

For those advocating awake FOI, would you use a SLN block? Or would you focus on atomization, etc.?

Personally, I find it hard to imagine justifying the awake approach. I would prefer an associate who is familiar with FOI and the need to keep the neck immobile to help once induction and paralysis are accomplished.

I do appreciate your comments, and in particular, the links to articles showing C1 mobility remains an issue with non-traditional forms of intubation such as the Glidescope.

 

[OB1🤙]

As doze said right off the bat, this is a subject reasonable people can disagree about.

There is no technique that guarantees no movement.

So YOU should do what YOU are most comfortable with. If that's AFOI, great. If that's asleep Glide, great. Whatever will result in less movement in your hands is the go-to technique for you.

For me, it's an asleep Glide, obviously assuming a reassuring airway.

 

[aredoubleyou]

A person who is so unstable and that close to impending neurological injury would have already have lost some neuro exam by the time they got to the or. Somebody has perpetuated this myth that people can be rendered a quad with the most subtle of movements (these people became quads in the field). It's kinda like high icp and herniating if you give 100 of propofol but not 150.

That being said for cya I will always intubated awake and have post intubation neuro exam documented. Technically I agree with someone above that fob under ga is least amount of movement.

 

[cincincyreds]

Hey, how about having neurosurgery place the patient in a halo first so just in case the patient coughs from your transtracheal injection they won't cough. Then do you awake FOI.

Anyone have an opinion on this?

 

[jetproppilot]

An asleep FOI, light wand, or Glidescope intubation in an immobile patient strikes me as far more controlled than an awake intubation. That's just my bias.

I completely agree.
I'd personally put the dude to sleep and GLIDESCOPE 'EM.
Easy. Eloquent. Effective.

 

[cchoukal]

I completely agree.
I'd personally put the dude to sleep and GLIDESCOPE 'EM.
Easy. Eloquent. Effective.

And, just for argument's sake, if he wakes up a quad and the surgeon points the finger?

 

[Mman]

And, just for argument's sake, if he wakes up a quad and the surgeon points the finger?

I point it right back. Which is a more likely cause of injury to the cord, asleep glidescope intubation or the surgical positioning followed by several hours of surgery in the near vicinity to the cord.

 

[IlDestriero]

I think asleep, probably paralyzed, and fully controlled is in the patient's best interest (provided they have a favorable airway). That's what I do and what I will continue to do in these situations.
I'm not going to do something that I think is definitely riskier to avoid the chance of being named in some lawsuit (that you'll probably be named in anyway). That's a sorry way to practice medicine.
If you want to do it awake, and you really think that's the best way, go for it. I think you're putting the patient at increased risk of coughing and catastrophe, however I wouldn't testify against you for choosing to do it awake.

 

[Idiopathic]

this is where evoked potentials might not be your friend, as they will be likely to check them after intubation. if the patient was functionally normal, but had decreased EPs following intubation and woke with a deficit, it would absolutely be put on you.

i think the safest thing for you and the patient is a smooth FOI, whether or not you can do it awake or asleep is up to the airway, i suppose. personally, when confronted with patients with myelopathic, but stable, spines, I prefer asleep fiberoptic/video DL. truly unstable spines probably warrant a more aggressive approach.

with that said, the patient will no doubt get more overall movement when flipping than anything you do during intubation, i would imagine.

 

[Mman]

this is where evoked potentials might not be your friend, as they will be likely to check them after intubation. if the patient was functionally normal, but had decreased EPs following intubation and woke with a deficit, it would absolutely be put on you.

i think the safest thing for you and the patient is a smooth FOI, whether or not you can do it awake or asleep is up to the airway, i suppose. personally, when confronted with patients with myelopathic, but stable, spines, I prefer asleep fiberoptic/video DL. truly unstable spines probably warrant a more aggressive approach.

with that said, the patient will no doubt get more overall movement when flipping than anything you do during intubation, i would imagine.

I do what is in the patient's best interest in a situation threatening paralysis. If it's a chip shot airway, an asleep glidescope is the easiest thing in the world and their neck does not move. Evoked potentials are useless for making the case it was the intubation, because even if they were grossly intact preop you don't have baseline evoked potentials with them awake to compare to. The EPs can be off and the patient can still be grossly intact.

Bad EPs after intubation don't tell you anything useful except that the patient is at higher risk for waking up with a neurologic deficit.

A lawyer can make whatever case they want to try to sue you. I'm confident I can make a better legal case than they can when the known risks of the surgery itself include paralysis.

 

[Idiopathic]

I do what is in the patient's best interest in a situation threatening paralysis. If it's a chip shot airway, an asleep glidescope is the easiest thing in the world and their neck does not move. Evoked potentials are useless for making the case it was the intubation, because even if they were grossly intact preop you don't have baseline evoked potentials with them awake to compare to. The EPs can be off and the patient can still be grossly intact.

Bad EPs after intubation don't tell you anything useful except that the patient is at higher risk for waking up with a neurologic deficit.

A lawyer can make whatever case they want to try to sue you. I'm confident I can make a better legal case than they can when the known risks of the surgery itself include paralysis.

right, and they didnt go to sleep with one. im not sure anyone here can say unequivocally that the fractured vertebral segment doesnt move with glidescope. i also know that AFOI does not prevent movement of the injured segment as well, but I think its the safest practice. the unparalyzed musculature of the awake patient seems to keep things stabilized a bit better as well, regardless of whether they cough or not. just my honest opinion. im not advocating one way or the other.

 

[jetproppilot]

And, just for argument's sake, if he wakes up a quad and the surgeon points the finger?

I can only control what I can control, dude.

Surgeon pointing the finger is out of my control.

I can't think of a better way to put a tube in a patient that I don't wanna move the neck:

GO TO SLEEP

GIVE SUX

GLIDESCOPE ON A MOTIONLESS PATIENT

Doesn't get any more eloquent than that.

 

[jetproppilot]

I think asleep, probably paralyzed, and fully controlled is in the patient's best interest (provided they have a favorable airway). That's what I do and what I will continue to do in these situations.
I'm not going to do something that I think is definitely riskier to avoid the chance of being named in some lawsuit (that you'll probably be named in anyway). That's a sorry way to practice medicine.
If you want to do it awake, and you really think that's the best way, go for it. I think you're putting the patient at increased risk of coughing and catastrophe, however I wouldn't testify against you for choosing to do it awake.

IlDestriero is a

REAL DOCTOR.

 

[Idiopathic]

I can see wanting to do an asleep procedure, its what i would choose 97% of the time im just curious why you all seem to think its definitely riskier to do an awake FOI, and secondarily why you then get lauded for being a 'real doctor' for it?

Are there case reports of people coughing themselves into quadriplegia?

 

[jetproppilot]

I can see wanting to do an asleep procedure, its what i would choose 97% of the time im just curious why you all seem to think its definitely riskier to do an awake FOI, and secondarily why you then get lauded for being a 'real doctor' for it?

Are there case reports of people coughing themselves into quadriplegia?

You've misinterpreted my quote.
I called Dest a REAL DOCTOR for practicing medicine like he sees fit and standing behind his training and going with his gut, as opposed to practicing
DEFENSIVE MEDICINE where a physician performs in a way that may be against his intuition but he does it anyway because of fear of legal s h it.

His choice of the Glidescope doesn't make him a Real Doctor.
HIS WAY OF PRACTICING MEDICINE, DOING THE BEST THING FOR THE PATIENT IN HIS OPINION, AND SCREW THE LEGAL OPINION OF THE LAWYERS,

does.

Since, if you're a REAL DOCTOR,

99.9999% of the time

YOUR ACTIONS AND OPINIONS ARE GOLDEN.

I just happen to agree with his opinion.

FOI is certainly a viable option.

 

[ssmallz]

If reasonable people can disagree then the answer doesn't really matter. If he winds up a quad you're F'd no matter what option you chose

 

[neusu]

Guy I know recently was confronted with a C1 fracture

What type of C1 fracture was it? For what it's worth there is the most room around the spinal cord at the foramen magnum/C1. Even if the guy did move it would be unlikely he'd piff himself.

 

[Idiopathic]

"pith"

and it doesnt necessarily matter how much room there is at the foramen. if its a big enough fracture of the C1, then the dens is fairly unrestricted and can injure the brainstem as well as the high cervical spinal cord. if it is a dens fracture then it could be a little more stable, but still extremely dangerous

 

[Mman]

"pith"

and it doesnt necessarily matter how much room there is at the foramen. if its a big enough fracture of the C1, then the dens is fairly unrestricted and can injure the brainstem as well as the high cervical spinal cord. if it is a dens fracture then it could be a little more stable, but still extremely dangerous

and a FOI isn't safer for the patient and doesn't protect you from a lawsuit with a bad outcome. Because you can have the best postintubation neuro exam you want. The patient could do jumping jacks in their c-collar with the ETT in place and if the patient wakes up with a deficit, your anesthetic management is STILL getting pulled into the lawsuit (if there is one).

That's how it works.

 

[pd4emergence]

"pith"

and it doesnt necessarily matter how much room there is at the foramen. if its a big enough fracture of the C1, then the dens is fairly unrestricted and can injure the brainstem as well as the high cervical spinal cord. if it is a dens fracture then it could be a little more stable, but still extremely dangerous

I think that we don't really know for a fact that intubation causes spinal cord injury in an unstable spine. The data just isn't very good. A few case reports in the literature, a lot of which had other factors that could have cause neurological deterioration. Two or so that seem to be associated, one of which the c spine injury was unrecognized and the patient underwent multiple dl's. It always amazes me the care with which we intubate these patients, then the spine surgeon comes in and positions them with the delicacy of a bull in a china shop.

 

[Idiopathic]

and a FOI isn't safer for the patient and doesn't protect you from a lawsuit with a bad outcome. Because you can have the best postintubation neuro exam you want. The patient could do jumping jacks in their c-collar with the ETT in place and if the patient wakes up with a deficit, your anesthetic management is STILL getting pulled into the lawsuit (if there is one).

That's how it works.

i only brought up the outcome side of it when discussing EPs and how they could be used to lay blame, not on the culture of litigation as it exists. i appreciate your insight here. im not sure anyone here can say that one or the other is safer, and i think thats part of the issue. either is defensible, I believe, and there are cases where i would choose one over the other. I think the patients that have significant instability would benefit more from a smooth AFOI. This of course presupposes that you can do this without your patient losing it and thrashing about, coughing, etc. I also think abandoning this procedure is acceptable as well, at which time you can do another technique. the reverse is not true.

 

[Idiopathic]

I think that we don't really know for a fact that intubation causes spinal cord injury in an unstable spine. The data just isn't very good. A few case reports in the literature, a lot of which had other factors that could have cause neurological deterioration. Two or so that seem to be associated, one of which the c spine injury was unrecognized and the patient underwent multiple dl's. It always amazes me the care with which we intubate these patients, then the spine surgeon comes in and positions them with the delicacy of a bull in a china shop.

I think ill argue that we also dont know for a fact that it doesnt cause injury. and i refuse to believe anyone can accurately say exactly what force they are applying in what vectors and what the effects are at C1, C2, etc. Radiographic studies have been done evaluating movement at various levels during videoscopic intubation, Ill see if I can find them.

 

[neusu]

"pith"

and it doesnt necessarily matter how much room there is at the foramen. if its a big enough fracture of the C1, then the dens is fairly unrestricted and can injure the brainstem as well as the high cervical spinal cord. if it is a dens fracture then it could be a little more stable, but still extremely dangerous

FWIW the dens is C2. It really is difficult to injure the spinal cord with C1 fractures only as C1 is the ring that hold the skull on the spine.

 

[Idiopathic]

FWIW the dens is C2. It really is difficult to injure the spinal cord with C1 fractures only as C1 is the ring that hold the skull on the spine.

yes im well aware what the dens is. my statement compared C1 with C2 injuries, at least in my mind. bad C1 injuries allow the dens to have greater anterior/posterior and lateral mobility which can injure the cord or more accurately the brain stem. there is not meant to be much if any flexion or extension of the C1-C2 joint. with a bad enough fracture of C1, you potentially have free motion around all axes of C1-C2, especially if there is ligamentous injury as well

 

[BLADEMDA]

As long as you are aware of the literature on this subject as well as the pro and con of each technique then there is no "best way" to secure the airway here. In my practice alone there would be several different approaches taken to secure the airway here by good physicians with great skills.

I hope Residents take the time to familiarize themselves with the literature on this subject as well as practice all the various techniques.

1. Awake Fiberoptic Intubation with field blocks
2. Asleep Fiberoptic intubation
3. Glidescope Intubation (minimial benefit for fractures above C3 vs standard Laryngoscopy)
4.. LMA then intubation via LMA (minimal benefit over DL especially for C3 fractures)
5. Direct Laryngoscopy with or without topicalization and field blocks

Despite all these debates there is no Evidence that a well controlled intubation causes harm to a patient with a cervical fracture especially a C1 fracture. That's why I urge those reading this thread to realize that there is no right answer here. Do what you are good at and what will benefit the patient. (my statement refers to adult patients without congenital abnormalities).

 

[BLADEMDA]

preintubation maneuvers, such as
chin lift/jaw thrust caused as much motion as some of
the intubation techniques. In a similar follow-up
study, Donaldson et al. (5) quantified the amount of
motion that occurs at an unstable C1-2 spinal segment
and showed that oro/nasotracheal intubation caused
similar motion; however, the chin lift/jaw thrust
caused more motion than either nasal or oral intubation.
The authors suggested that great care should
be taken while performing the chin lift/jaw thrust
maneuvers in preparation for intubation. Recently,
Lennarson et al. (7) investigated the effect of
laryngoscope-guided orotracheal intubation after posterior
destabilization of the C4-5 segment in cadavers.
They showed that the predominant motion of the
unstable segment changed from extension to flexion
after the injury; however, the degree of motion was
small and unaffected by the application of traction.
Kihara et al. (4) measured C-spine movement in three
patients with unstable C-7 segments from metastatic
disease who were tracheally intubated through the
ILM. They found that the degree of segmental flexion/
extension and posterior movement of the C0-6 segments
was similar in patients with stable C-spines.

 

[BLADEMDA]

Anesthesiology 2006; 104:1293–318 © 2006 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Airway Management in Adults after Cervical Spine Trauma
Edward T. Crosby, M.D., F.R.C.P.C.*



There are no outcome data that would
support a recommendation for a particular practice option for
airway management; a number of options seem appropriate
and acceptable.

 

[BLADEMDA]

Fiberoptic intubation (FOI) is generally regarded as the preferred method to achieve endotracheal intubation in patients with cervical spine instability. When performed electively, FOI has a very high level of success. Nevertheless, rarely, FOI may fail. Recently, using the fiberoptic scope to obtain a view of the glottis, with the endotracheal tube being inserted independently, guided by the fiberoptic view has been described. In this report, we describe our experience with a variation of this technique in both adults and children with occipito-cervical instabilities in whom FOI failed.



Airway management in patients with unstable occipito-cervical and upper cervical (C1-C2) junctions presents a challenge to the anesthesiologist because intubation may produce pathological cervical spine motion, thus putting the spinal cord at risk of injury.1 Intubation with direct laryngoscopy1,2 and other intubation methods, such as the Bullard Laryngoscope®,3–5 GlideScope®,6,7 and light wand,6 produce varying degrees of extension at the occipito-cervical junction.

Fiberoptic intubation (FOI) is used frequently in patients with unstable occipito-C1-C2 because it is associated with minimal spine motion. However, the laryngeal inlet can be displaced and/or difficult to access with the fiberoptic bronchoscope in such patients because of severe spinal deformity or traction. Consequently, conventional FOI may occasionally fail in these patients because of difficulty in threading either the fiberoptic bronchoscope or the oral endotracheal tube (OET) into the trachea.8


http://www.anesthesia-analgesia.org/content/108/6/1937.full

 

[BLADEMDA]

Guy I know recently was confronted with a C1 fracture and elected to do an awake FOI with transtracheal and SLN blocks. After the tube was in, the patient, whose head was sandbagged and taped in place, was able to move all extremities on command. Induction proceeded and the anesthesiologist felt that he had safeguarded himself against lawsuits that might misconstrue a surgical (or any other non-anesthetic) complication with injury that occurred during intubation.

He was asked about a FOI or glide scope intubation asleep and paralyzed and he felt that his approach was superior because the patient demonstrated neurologic competence after intubation.

The possibility that the patient might cough due to transtracheal blockade placement or a less-than-perfect set up prior to FOI concerned some who heard about this scenario.

What say you?

Nice job by the Anesthesiologist. He did the approach recommended by many academic Anesthesiologists.

Other approaches include asleep Fiberoptic intubation as well. My group has performed asleep Fiberoptics with great success many times.

Or, once the view of the cords are visualized then appropriate induction meds are given prior to placing the ETT through the cords.

A few of my partners use the glidescope in this situation with or without a halo. Great success with many, many cases over the years.

It is easy to get lazy these days and just use the LMA, Glidescope, etc over the Fiberoptic.
If you want to maintain proficiency with the Fiberoptic then you must use it more than once a year.

 

[BLADEMDA]

To the Editor:
We read with great interest, but equal concern, the recent article by Rosenstock et al.1 and the accompanying editorial by Fiadjoe and Litman.2 Both publications confirm that flexible bronchoscopy "will still be required" and that anesthesiologists in "large number(s)… lack the commitment and desire to master fiberoptic intubation" and concluding that using a rigid videoscope represents a paradigm shift in anticipated difficult airway management is misguided. Indeed, in expert hands, not only was flexible bronchoscopy a reliable and efficient technique, equivalent in success rate and time to intubation to the McGrath video laryngoscope, but 7 of the 48 patients randomized to the McGrath video laryngoscope could not undergo the awake technique! The exclusion criteria (limited mouth opening and neck pathology prohibiting recurrent laryngeal nerve block via the transtracheal method) were also so restrictive that it is no surprise that the success rates of the two methods were equivalent. Head and neck pathology has already been associated with a high failure rate using video laryngoscopy.3 Perhaps any device chosen, including traditional Macintosh and Miller laryngoscopes, when this patient population was eliminated for investigation, would result in equivalent success. Given the fact that the success and time to perform an awake intubation was equivalent "in expert" hands, perhaps the recommendations should be that anesthesiologists and anesthesia trainees use flexible bronchoscopy more frequently to develop and maintain skills that require more practice and expertise rather than seek alternative and potentially limited devices that subjugate one's required skillset. If we continue to compromise the development and maintenance of flexible bronchoscopic skills, future studies will inevitably demonstrate the superiority of the rigid devices in limited patient populations because of a lack of anesthesiologists who are skilled flexible bronchoscopists.
As clinicians and educators, we must squelch the desire to further encourage the steady erosion of advanced airway skills. Although we thank the authors for further demonstrating that video laryngoscopic methods have their role in managing patients with anticipated difficult airways, the need to perform awake flexible fiberoptic intubation is still an absolute vital skill that requires a renewed educational emphasis so that anesthesiologists can and will use this technique when indicated. Residency programs and airway workshops need to spend more time teaching the more difficult to master fiberoptic technique and less time teaching video laryngoscopy, which is easier to learn and maintain mastery of in the first place.
Adam I. Levine, M.D.,* Andrew B. Leibowitz, M.D.

 

[Planktonmd]

Blade...
You lost me ... as usual... may I ask you to tell me in a few words what you are attempting to say???

 

[BLADEMDA]

Blade...
You lost me ... as usual... may I ask you to tell me in a few words what you are attempting to say???

There are many Anesthesiologists who suck with the Fiberoptic. They either NEVER learned the technique adequately or lost proficiency over the years. For those practitioners a Glidescope is a much better choice here.

There really isn't any outcome data to suggest that one approach is safer than another. In my practice alone we have performed hundreds of intubations for cervical fractures over the years utilizing all the techniques I mentioned without any difference in outcome.

Thus, in your hands a FOI may be the best choice but in other hands the Glidescope makes sense.

 

[Planktonmd]

There are many Anesthesiologists who suck with the Fiberoptic. They either NEVER learned the technique adequately or lost proficiency over the years. For those practitioners a Glidescope is a much better choice here.

There really isn't any outcome data to suggest that one approach is safer than another. In my practice alone we have performed hundreds of intubations for cervical fractures over the years utilizing all the techniques I mentioned without any difference in outcome.

Thus, in your hands a FOI may be the best choice but in other hands the Glidescope makes sense.

Thanks... Couldn't agree more!

 

[MSP1957]

Totally agree with you. FOI is becoming a lost technique. I practice at least once a week in anticipation of the patient who can not adequately open their mouth. Glide scope will be useless.

 

[anes121508]

Read this thread once when I was a CA-1....and now that I'm taking orals soon, I did a google search and added "sdn" (as I usually do to find some good debate. Either way, a few questions...


Awake FIO vs Awake Visualize cords and push drugs:
- Concern with totally awake is obviously coughing. I typically use the spray as you go technique after the neb, however some coughing is common with the lido. Never done trans-tracheal block, but seems like you will absolutely cough (and it helps distribute the lido). So, how are you doing an AFOI with zero sedation and zero cough?

Cervical Fracture (high risk) vs TBI with elevated ICP:
- Is coughing just as detrimental? Would this change your approach?

Awake Trach:
- When is this used and how feasible is this really? Not usually a huge deal when we did these for laryngectomy folks in a controlled OR setting, but trauma situation is obviously different

Cervical fracture/TBI, Bad airway, Probably can't mask 2/2 BMI 130 and beard, bloody airway, combative.....now what?

- Sedation keep spont and take a peak with fiber and induce if you can see cords? vs Right to the Trach w/just the right amount of sedation?

 

[anbuitachi]

personally i'd do AFOI for this guy as well. Also in terms of defensibility, i think that is your best bet. The recommended approach is fiberoptic for unstable necks. So you are left with awake vs sleep. I'd choose awake in case desat happens or the airway collapses on induction or whatever. Any sort of mask ventilation will probably move the neck (at least to the lawyers).

 

[deleted697535]

If exam situation I think if you go straight to afoi and they say to you it fails you're kind of stumped right? Like you can't legit say I'm gonna have to do afoi but now I need to backtrack and do laryngoscopy?

So in that case I'd do glidescope with roc/suggamadex ready *if no airway concerns otherwise

I'd do afoi if airway concerns with brief nerro exam after if airway was ****e

 

[anes121508]

If exam situation I think if you go straight to afoi and they say to you it fails you're kind of stumped right? Like you can't legit say I'm gonna have to do afoi but now I need to backtrack and do laryngoscopy?

So in that case I'd do glidescope with roc/suggamadex ready *if no airway concerns otherwise

I'd do afoi if airway concerns with brief nerro exam after if airway was ****e

just to play devils advocate....you are doing an afoi on a cervical spine patient and doing a transtracheal block and they cough? you use spray as you go technique and they cough? What's the percent chance they cough for your method of topicalization of the cords/trachea? Won't that coughing likely be detrimental to the cord?