C7 fracture, how would u manage airway

[snowman8]

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This past week while on call, 1 hr before the end of my shift, I recieved a page on my trauma pager, "lip amputation eta 5min". I didn't think twice about it, but then about 15 min before the end of my shift a male in his 20's shows up in the GOR with a partial leg amputation and C7 fracture to have a comlete amputaion of his leg after falling of his crotch rocket. He was hemodynamicaly stable.

The new CA-3 on call was there to take over so I handed over the paton, although I stuck around just in case any assistance was needed. The attending decided to perform an awake nasal. The surgeon was pushing for inducing the pt and for a DL under inline stabaliztion. The CA-3 basicaly told the surgeon to shut the f*ck up and let anesthesia do their job. The awake nasal intubation ended up being a painful bloody mess. The surgeon stepped up again and insisted that the attending attempt the awake nasal. By that time, the bleeding was worse and he could also not see a thing. The attending turned around to grab something and the CA-3 noticed that the tube was fogging and just shoved it in the pie hole. Score! A blind nasal. Pretty smooth.

How would you manage this airway. No signs or risk factors for difficult mask/intubation besides C7 frx. I personaly would have induced with inline stabilization and if I could not have seen anything on DL, slipped in an LMA and intubated through it. We have a glide scope, ideal, but no where to be found.

 

[zippy2u]

Sounds like your typical teaching hospital circle jerk flail. Appears like the surgeon made more sense than the anes. attending. Yup, in-line neck stabilization, bang drugs and put the tube in. Keep em paralyzed and wheel up to surgery. Of course, you will do a cursory neuro check prior to bangin' your drugs. Regards, ----Zippy

 

[dfk]

first thing i thought of was glide scope with MILS

 

[apma77]

if fracture is unstable he buys an awake fiberoptic ..oral (not nasal cause of the bloodiness of it)
if neck is stable id do an asleep fiber..if that didnt work then DL as back with MILS

 

[Planktonmd]

If the airway looks OK then I don't know why you should do anything different than what you do to any trauma patient with known or suspected cervical injury:
Inline stabilization + RSI + tube. If you have a glidescope then why not, use it!
If the airway looks horrible: (Example to that would be a Dwarf with Macroglossia, Micrognathia, Ankylosing spondylitis and Crouzon Syndrome) then I would do an awake oral fiberoptic intubation with proper topical anesthesia and airway blocks.
Why did your attending want to intubate him nasally?

 

[SleepIsGood]

Awake FOI...unless really easy looking airway, which would mean RSI+inline stabilization+tube

I thought Blind Nasal intubations were a thing of the past. From what I heard from an attending, you have to put your ear next to the tube and then just keep sliding it in until you hear BS. The fog thing could throw you off...I think you would still see 'fog' if you were in the esophagus.

I'd like to try blind nasal hopefully before residency is over....

 

[Planktonmd]

if neck is stable id do an asleep fiber..

Trauma patients are usually full stomach.

 

[Bertelman]

I read the OP just waiting to find out what a lip amputation was.


🙁

 

[Apollyon]

If the airway looks OK then I don't know why you should do anything different than what you do to any trauma patient with known or suspected cervical injury:
Inline stabilization + RSI + tube. If you have a glidescope then why not, use it!
If the airway looks horrible: (Example to that would be a Dwarf with Macroglossia, Micrognathia, Ankylosing spondylitis and Crouzon Syndrome) then I would do an awake oral fiberoptic intubation with proper topical anesthesia and airway blocks.
Why did your attending want to intubate him nasally?

Dude, I'm calling you from the ED for that - that's ALL you!

 

[Mista Suprane]

We have a glide scope, ideal, but no where to be found.

apparently its been MIA for a couple of weeks now; when i first heard about this case, i was thinking that it would have certainly come in handy for you guys.

 

[Noyac]

anyone have any numbers on the actual pts who come in with cervical fx's who were intubated with ILS by an anesthesiologist and suffered a neurologic injury that wasn't present prior to intubation? I would bet it is very small.

 

[Arch Guillotti]

This is easy.

Rapid sequence lightwand w/all the lights in the room turned out.

That always gets a few oohs and ahhs.

 

[Arch Guillotti]

Seriously though I would probably just do an RSI w/cricoid and inline. If he had an unstable neck or neurological deficit I would consider doing it awake. I don't think that this is necessarily the "right" way to do things but it is part of what we are taught in residency. If you go this route you had better make darn sure you have excellent airway topicalization because he is a full stomach prolly and is young and dumb probably. So you don't want him gagging or bucking or coughing - if he does this then he is apt to move his neck more that he would if you just did a regular old DL.

So, unless he has an unstable neck I would do a regualr old staright up RSI, glidescope if ya got it. I would NOT do a nasal on this guy. A blind nasal saved my @ss a couple of times but I don't think that this is the time to do it.

 

[Laurel123]

Pre oxygenate. RSI and tube with a glidescope. The neck doesnt even have to budge. I actually stay away from awake foi in neck fracture patients. These young guys will buck and gag and probably .ove their neck around more than a nice alseep intubation

 

[Noyac]

I agree that the coughing and bucking from topicalization (transtracheal) and awake intubation is probably more dangerous than the asleep DL. Do you guys keep the c-collar on when doing the topicalization and the awake intubation?

Also, this surgeon was leaning towards asleep but what if the surgeon says he needs awake intubation?

 

[Planktonmd]

I agree that the coughing and bucking from topicalization (transtracheal) and awake intubation is probably more dangerous than the asleep DL. Do you guys keep the c-collar on when doing the topicalization and the awake intubation?

Also, this surgeon was leaning towards asleep but what if the surgeon says he needs awake intubation?

I will do awake FOB on cervical trauma only if:
1- The airway looks really bad and
2- The patient is smart enough and awake enough to cooperate.
And these 2 conditions are rare in trauma patients.
So, in the rare occasions where that might be the plan you do good topical anesthesia of the oral cavity then atomize Lido 4 %, then someone holds the head with the collar on and you do a transtracheal.
You don't need to remove the collar for FOB and that's where the beauty is.

 

[Hockeyguy]

The awake nasal intubation ended up being a painful bloody mess.

Did you guys use Afrin?

 

[Noyac]

I will do awake FOB on cervical trauma only if:
1- The airway looks really bad and
2- The patient is smart enough and awake enough to cooperate.
And these 2 conditions are rare in trauma patients.
So, in the rare occasions where that might be the plan you do good topical anesthesia of the oral cavity then atomize Lido 4 %, then someone holds the head with the collar on and you do a transtracheal.
You don't need to remove the collar for FOB and that's where the beauty is.

Yes, however I don't find that atomized lido is very reliable. I still try it and if it doesn't work I go to viscous lido swish and swallow. Not my first choice in a trauma "full stomach" for obvious reasons. I always do the transtracheal and I have someone try and help me stabilize the neck when doing this. They cough but it usually isn't too much but I keep the c-collar on during the transtracheal.

 

[seinfeld]

Correct me if i am wrong, the neck doesnt articulate at C7 when doing a DL. If i remember correctly it more mid cervical vertebrae that move the most.

In my opinion in line stabliization is just like cricoid pressure. Hard to prove it works and no one is willing to do more randomized studies to show its worthless. And also like cricoid it is rarely done correctly. If youre really worried about paralyzing someone do an awake oral Fiber. I agree that in cases of trauma it is rarely easy to accomplish for multiple reasons. IN the end just be gentle no matter what you do.

 

[epidural man]

From what I heard from an attending, you have to put your ear next to the tube and then just keep sliding it in until you hear BS.

I'd like to try blind nasal hopefully before residency is over....

I saw one of my attendings do this in the unit - coolest thing ever.