C1 fracture and awake FOI

[anes121508]

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).

my understanding is that mask ventilation with any jaw thrus has been shown to move the neck quite a bit so you are right in that aspect.....but how are you going to ensure that the patient doesn't cough when you topicalize the trachea/cords?

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[deleted162650]

how are you going to ensure that the patient doesn't cough when you topicalize the trachea/cords?

Can you show me just one case report of a neurologically intact patient in a C-collar who coughed and paralyzed themselves??

If a cough in a collar is enough to make them a quad, you expect the cord to survive the flip??

 

[deleted697535]

I don't regularly do transtracheal for afoi.
I'd do dexdor, small amount of midaz then nebulized lido.
I haven't seen much coughing with neb lido but admittedly n<15 for that one

 

[nimbus]

I don't regularly do transtracheal for afoi.
I'd do dexdor, small amount of midaz then nebulized lido.
I haven't seen much coughing with neb lido but admittedly n<15 for that one

Nebulized lido works as well as transtracheal, especially if you have the patient pant a bit.

 

[pgg]

Your awake FOI won't be unsuccessful on the oral exam unless the technique you describe is ridiculous.

An awake cough isn't going to paralyze anyone. Violent bucking and twisting and thrashing because you did a clumsy painful assault on a poorly topicalized airway - maybe.

One last awake post-intubation neuro exam to document before the surgeon has a chance to surgically paralyze the patient is a nice AFOI perk.

 

[deleted59964]

glyco for secretions and to improve quality of topicalisation

remifentanil for sedation and as an anti tussive (it’s an awesome cough suppressant). 50 mcg increments and infuse 0.1-0.25mcg/kg/min

topicalise carefully

afoi

coffee

 

[deleted697535]

In our oral we had an acute unstable cspine with a difficult airway features from past medical history. Most passed.
One guy who failed said AFOI and when pushed on his plan B, he said DL

Thats my reasoning for saying the above

 

[Ezekiel2517]

If a cough in a collar is enough to make them a quad, you expect the cord to survive the flip??

This is why for years I have been proposing that spine surgeons must learn how to perform these procedures upside down.

 

[deleted162650]

This is why for years I have been proposing that spine surgeons must learn how to perform these procedures upside down.

Yes, a true master would operate lying on scaffolding on his back like Michelangelo painting the Sistine Chapel.

At least that's what you tell them to appeal to their ego.

 

[anes121508]

Can you show me just one case report of a neurologically intact patient in a C-collar who coughed and paralyzed themselves??

If a cough in a collar is enough to make them a quad, you expect the cord to survive the flip??

Actually hard to find anything that is clearly linked to the management of the airway other than people just just didn't use any sort of inline stabilization.

Many studies looking at how much the vertebrae move during different maneuvers (LMA, Glide, Masking, Dl). Nothing looks at coughing. No clue how well the c-collar works to prevent unwanted movement of the neck.

 

[anes121508]

Nebulized lido works as well as transtracheal, especially if you have the patient pant a bit.

Agree, it works well (I don't do transtracheal either). However, my observation is that it does not work 100% of the time. Which is why I posed the question about coughing.

 

[deleted59964]

Yes, a true master would operate lying on scaffolding on his back like Michelangelo painting the Sistine Chapel.

At least that's what you tell them to appeal to their ego.

this approach would also ensure a diligent approach to preventing blood loss

 

[anes121508]

Your awake FOI won't be unsuccessful on the oral exam unless the technique you describe is ridiculous.

An awake cough isn't going to paralyze anyone. Violent bucking and twisting and thrashing because you did a clumsy painful assault on a poorly topicalized airway - maybe.

One last awake post-intubation neuro exam to document before the surgeon has a chance to surgically paralyze the patient is a nice AFOI perk.

Three ways to block below the cords in my mind: 1. Transtracheal 2. Nebulizer 3. Go down with the scope and spray.

The only time I've ever seen transtracheal is on youtube by the guy at MGH. His coughing is pretty violent after he gets the lido sprayed in his trachea. So in my mind that's out. Nebulizer isn't 100% effective. Spraying gently with the fiberoptic still causes a pretty good cough once in a while (less so after a nebulizer attempt).

So when you do your nebulizer and you go in and start to advance through the cords and the guy is bucking and coughing cuz the neb didn't do it's job for whatever reason. More nebulizer? Or back up right before the cords, push a little remi, then advance?

 

[anes121508]

In our oral we had an acute unstable cspine with a difficult airway features from past medical history. Most passed.
One guy who failed said AFOI and when pushed on his plan B, he said DL

Thats my reasoning for saying the above

haha enough said

 

[anes121508]

glyco for secretions and to improve quality of topicalisation

remifentanil for sedation and as an anti tussive (it’s an awesome cough suppressant). 50 mcg increments and infuse 0.1-0.25mcg/kg/min

topicalise carefully

afoi

coffee

100% agree with the remi and glyco

 

[Arch Guillotti]

If a cough in a collar is enough to make them a quad, you expect the cord to survive the flip??

Do the AFOI. Flip the patient. Do the “neuro exam”. Put them to sleep, problwm solved.

 

[deleted697535]

I forgot about doing the neuro exam after the flip! Bonus points.

I do love this site. Wish i had found it years ago. This thread is final exam topic gold!

 

[T-burglar]

If you just jam in it in there and overpower their attempts to stop you they’ll be moving all 4 extremities throughout the intubation

 

[deleted162650]

If you just jam in it in there and overpower their attempts to stop you they’ll be moving all 4 extremities throughout the intubation

Well, at least at the beginning they will be.

 

[IkeBoy18]

During my CA1 year I spoke with a neurosurgeon about the C-collar and what exactly it is supposed to be accomplishing, as many patients have some mobility in them and its actively stretching the neck. He states the only thing it does it prevent lateral/rotational translational movement which could theoretically be bad. The anterior/posterior movement is usually not a big issue.

I also agree with the flip and securing of the mayfield being most traumatizing event to the patient and if anything happens, thats where it will happen.

I just cant see intubation with any of the aforementioned techniques causing a large neuro deficit, especially in the face of the flip. This is almost like how in anesthesia were pressured to save 2 cents here and there on drugs, etc in the OR when surgeons can be 20 min late and burn off, $2000 in OR time, or open the wrong supplies etc, but then everyone is always looking to us to "cut costs." IE anesthesia's fault.

 

[ethilo]

One of our old school neuroanesthesia attendings (you know, the guy with all the good old time stories) told me they used to regularly perform AFOI then have the patient position themselves in the prone table, hook the circuit up and turn on the gas. Needless to say, he's got a killer AFOI technique that I'm taking with me to the grave!

 

[Psai]

One of our old school neuroanesthesia attendings (you know, the guy with all the good old time stories) told me they used to regularly perform AFOI then have the patient position themselves in the prone table, hook the circuit up and turn on the gas. Needless to say, he's got a killer AFOI technique that I'm taking with me to the grave!

Thanks for nothing

 

[pgg]

Needless to say, he's got a killer AFOI technique that I'm taking with me to the grave!

Are you saying we'll never guess your ONE WEIRD TRICK to intubating unstable c-spines?

 

[abolt18]

Are you saying we'll never guess your ONE WEIRD TRICK to intubating unstable c-spines?

Yeah, sounds like it was indeed "needless to say"

 

[anbuitachi]

In our oral we had an acute unstable cspine with a difficult airway features from past medical history. Most passed.
One guy who failed said AFOI and when pushed on his plan B, he said DL

Thats my reasoning for saying the above

Wow he failed just cause of that? That's insane! What were some plan B's that passed? Ecmo?

 

[pjl]

Three ways to block below the cords in my mind: 1. Transtracheal 2. Nebulizer 3. Go down with the scope and spray.

The only time I've ever seen transtracheal is on youtube by the guy at MGH. His coughing is pretty violent after he gets the lido sprayed in his trachea. So in my mind that's out. Nebulizer isn't 100% effective. Spraying gently with the fiberoptic still causes a pretty good cough once in a while (less so after a nebulizer attempt).

So when you do your nebulizer and you go in and start to advance through the cords and the guy is bucking and coughing cuz the neb didn't do it's job for whatever reason. More nebulizer? Or back up right before the cords, push a little remi, then advance?

If you ever have a patient you are waking back up to do an awake fiber optic on (rare, I know) then trans tracheae is great while they are still sleepy from being put out the first time. That is the only time I use it. Nebulized lido otherwise is a pretty effective method, with minimal fuss factor. I normally follow with a little splash of lido through an atomizer aimed near their cords.

 

[AdmiralChz]

Wow he failed just cause of that? That's insane! What were some plan B's that passed? Ecmo?

In practice, we often would confirm (or at least suggest) intact spinal cord function with pre-flip and post-flip SSEPs/MEPs after the airway was secured. Time consuming, but useful if you are very worried about positioning and turning. Useful in a uncooperative/intoxicated patient precluding am awake neurological exam as described earlier

 

[deleted697535]

Wow he failed just cause of that? That's insane! What were some plan B's that passed? Ecmo?

Plan b's that passed that I know of all included videolaryngoscopy. That was my plan b too