Calling Anesthesia

[TheComebacKid]

This is not meant to be a pissing match between the two specialties regarding who is better at airway management (there are prior threads in both forums about this).

Lets say hypothetically you work at a hospital that has 24/7 anesthesia in house, and they are available and willing to respond to the ED.

Under what circumstances are you calling, if any?

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[TheComebacKid]

Follow up question:
If you have anesthesia in house and you don’t call, and the patient has a catastrophic outcome (say anoxic brain injury), is there precedent to sue the EP for not calling anesthesia?

 

[deleted813736]

I have worked in a few places in my time. I dont think Anesthesia is rady and waiting for the ER to call them down, its a rarity. Theoretically we should be able to handle everything although there is rarely an angioedema that you want to do intranasal intubation (my ER does not provide us the intranasal tools to use to intubate) or a super obese male that you are worried about you can call them for.
Personally I have called anesthesia twice in my career, once for an intranasal angioedema intubation (Awake) and pediatric child that had an anterior airway i just couldn't see with a miller or mac blade. Both times they were very helpful and no poor outcome.

I do believe a decent lawyer would certainly bring up the fact you had an 'airway expert' available and you messed around with the airway for multiple attempts leading to anoxic injury. if things are looking south, theres no harm in calling.

 

[DoctorJDO]

My hospital created a difficult airway response team. I like it. Anywhere in the hospital someone calls a difficult airway overhead and EM, anesthesia, critical care, and ENT show up, each with their respective airway advice and expertise. Once everyone learned to put their egos aside it functions pretty well. The one who calls is "in control", but nice to have another expert standing by who may have a different approach than you. If you have a high risk situation such as difficult airway, why not load the boat. Similar to when when a colleague can't get a hip or shoulder back in or can't get a lumbar puncture, 9/10 they don't need ortho or IR consults, they just need a second ER doc to try it with their own slightly different approach.

I've called the difficult airway team 3 times in the past 3 years. Twice they all hung out bedside on standby with their tools and ENT prepped the neck, and I intubated easily. The other time I had ENT do a fiberoptic aintree scope because the patient had a neck mass. Did I really need an anesthesiologist or ENT to save the day? No, but this is high risk and it was nice to have a team there.

In EM we are trained to have plan A, B, and C ready for disaster, yet we often let egos get in the way for airway stuff and ditch plan B and C in favor of plan A = I'm a BAMF and good at intubations. I like the airway team for this.

Twice I responded to the floor and endo suite for difficult airway called overhead. blood/vomit and CPR/chaos were involved, so I claimed to be "the most experienced" in the situation and intubated. In subsequent interactions, I feel like the other specialists involved have treated me with a little more respect than usual, but maybe I'm imagining that!

 

[pkwraith]

We have a special Airway alert at on of my tertiaries although I've never had to use it, although based on it existing, I would pretty much be forced to use it for any angioedema-type stuff.

The only time I've called anesthesia in the last few years was actually in a fem fracture patient with poor pain control due to opioid use history + bad COPD on O2 and was already having desat issues, although didn't need to be tubed. Even with ketamine and I didn't really want to intubate this difficult airway patient. Middle of the day. I figured what the heck, asked nicely if they could do a iliacus block until ortho could do surgery as it would be pretty helpful for the patient, and anesthesia would do it as almost standard of care at my training hospital. The resident said no we don't do pain procedures here, and that was the end of that.

 

[Dr. Rude]

Anesthesiologist here. Current ER group we have is awesome. When they call for help (very very rarely) I always know it will be something really bad.
Last ER group was clinically weak called us a lot for Tubes and central lines.

 

[thegenius]

This is not meant to be a pissing match between the two specialties regarding who is better at airway management (there are prior threads in both forums about this).

Lets say hypothetically you work at a hospital that has 24/7 anesthesia in house, and they are available and willing to respond to the ED.

Under what circumstances are you calling, if any?

I would call them for all Post-LP headaches, and they can respond to floor codes, and to please respond to me when I need help intubating - which means I'll be happy for them to intubate. I don't need them there to be "backup". If I feel I can't do it or it's too hard or whatever, then they can do it. I think I've asked for their help 3 times in the past 8 years...all angioedema that is better equipped with fancy equipment in the OR that I don't have in the ED.

Pretty straight-forward.

 

[thegenius]

My hospital created a difficult airway response team. I like it. Anywhere in the hospital someone calls a difficult airway overhead and EM, anesthesia, critical care, and ENT show up, each with their respective airway advice and expertise. Once everyone learned to put their egos aside it functions pretty well. The one who calls is "in control", but nice to have another expert standing by who may have a different approach than you. If you have a high risk situation such as difficult airway, why not load the boat. Similar to when when a colleague can't get a hip or shoulder back in or can't get a lumbar puncture, 9/10 they don't need ortho or IR consults, they just need a second ER doc to try it with their own slightly different approach.

I've called the difficult airway team 3 times in the past 3 years. Twice they all hung out bedside on standby with their tools and ENT prepped the neck, and I intubated easily. The other time I had ENT do a fiberoptic aintree scope because the patient had a neck mass. Did I really need an anesthesiologist or ENT to save the day? No, but this is high risk and it was nice to have a team there.

In EM we are trained to have plan A, B, and C ready for disaster, yet we often let egos get in the way for airway stuff and ditch plan B and C in favor of plan A = I'm a BAMF and good at intubations. I like the airway team for this.

Twice I responded to the floor and endo suite for difficult airway called overhead. blood/vomit and CPR/chaos were involved, so I claimed to be "the most experienced" in the situation and intubated. In subsequent interactions, I feel like the other specialists involved have treated me with a little more respect than usual, but maybe I'm imagining that!

Nice to work in an academic hospital. No way in the community that the community ENT, Anesthesia, CCU, and EM (who is not already working) all show up together, 24/7, ready to help out!

 

[thegenius]

(I should know this...) does etomidate in-of itself blunt laryngeal reflexes? very high doses of propofol can, if I recall. Not sure about ketamine.

 

[CajunMedic]

I can only think of a couple of reasons: Angioedema when they would need their fiberoptic and other equipment is needed, etc. or a situation where there is airway anatomy issues, repairs, etc. where they would need to be tubed in the OR. Had a situation of someone whose complex tongue/airway flaps etc. from cancer dehisced and were bleeding. Wound up going to the OR with Anesthesia, ENT, and surgery to get intubated and then back to us to wait for transport out.

 

[oldtown]

Follow up question:
If you have anesthesia in house and you don’t call, and the patient has a catastrophic outcome (say anoxic brain injury), is there precedent to sue the EP for not calling anesthesia?

I can only assume you absolutely can be sued for not calling anesthesia for a difficult airway, because I’ve learned you can also be sued for ONLY calling anesthesia.

 

[turkeyjerky]

I can only assume you absolutely can be sued for not calling anesthesia for a difficult airway, because I’ve learned you can also be sued for ONLY calling anesthesia.

Care to elaborate?

 

[oldtown]

Care to elaborate?

I can’t for the time being, unfortunately.

 

[DoctorJDO]

Nice to work in an academic hospital. No way in the community that the community ENT, Anesthesia, CCU, and EM (who is not already working) all show up together, 24/7, ready to help out!

not academic, but we all have the same contract group so it's easier to get everyone on the same page

 

[RuralEDDoc]

My hospital created a difficult airway response team. I like it. Anywhere in the hospital someone calls a difficult airway overhead and EM, anesthesia, critical care, and ENT show up, each with their respective airway advice and expertise. Once everyone learned to put their egos aside it functions pretty well. The one who calls is "in control", but nice to have another expert standing by who may have a different approach than you. If you have a high risk situation such as difficult airway, why not load the boat. Similar to when when a colleague can't get a hip or shoulder back in or can't get a lumbar puncture, 9/10 they don't need ortho or IR consults, they just need a second ER doc to try it with their own slightly different approach.

I've called the difficult airway team 3 times in the past 3 years. Twice they all hung out bedside on standby with their tools and ENT prepped the neck, and I intubated easily.

Much love to you all for pulling this off, because this seems costly and wasteful for all but the most extreme of airway cases.

 

[WilcoWorld]

This is not meant to be a pissing match between the two specialties regarding who is better at airway management (there are prior threads in both forums about this).

Lets say hypothetically you work at a hospital that has 24/7 anesthesia in house, and they are available and willing to respond to the ED.

Under what circumstances are you calling, if any?

I will call if the airway is predictably difficult AND the patient's ventilating well enough that I have time to wait.

Think: known head & neck cancer with hemoptysis and neck swelling but an O2>92% who can tolerate secretions.

#1 reason to call "this patient should be tubed in the OR and they have enough time to wait for me to get them there"

 

[TheComebacKid]

I think the EM mindset is historically that we should be able to manage every airway and not require backup. While that is a good mindset from a training standpoint, I think it's really egotistical and detrimental to not utilize appropriate resources if you have them available to you, and it could potentially lead to a better or safer outcome for the patient.

Calling anesthesia is not a failure. As someone alluded to earlier, I would say it should be part of the back up/difficult airway algorithm. I have called them once as an attending, and a handful of times witnessed as a resident, and they were always awesome. Never hip checked me out of the way (even when I was a trainee) but actually gave some good pointers. I'm sure people have horror stories when it doesn't go so well too, but most of the anesthesia folks I've worked with respect what we do in the ED and don't want to take over, they just want to assist.

The issue of angioedema always comes up. I've found two flavors of angioedema patients... The ones that are literally crashing and need a surgical airway immediately. And the ones that won't crash for another few hours and will likely get better and go home, but you have enough time to set up your fiberoptics/topicalization etc. If it's the former case, sure, you don't have time to call anesthesia (or a surgeon for that matter) you just have to cut the neck. But in the latter case, you often have enough time to get them involved, and it's actually super helpful to have a second set of hands when doing awake fiberoptic.

Controversial opinion: I think if you are calling anesthesia sparingly, it probably means that you are experienced enough with airway to know when you are in treacherous waters and you need some additional assistance.

Airway management is probably the most humbling thing we do in EM.

 

[The Knife & Gun Club]

So far in my 2 years of residency I’ve called out in house anesthesia team twice - once for a bad angioedema that I felt needed to be tubed in the OR with ENT available for a surgical airway, and once for someone who was fine but their surgeon wanted them intubated to “decrease their metabolic demand.”

The angioedema one Id call for all day every day if they’re available. The metabolic demand one I called because I (and my attending and our med director) didn’t believe airway management was emergently indicated…if the surgeon wanted them tubed for a ridiculous reason they’d have to do it their way with their people.

 

[BoardingDoc]

Care to elaborate?

Presumably a lawsuit where there was a difficult intubation: ER knew that and called anesthesia. Anesthesia couldn't get the tube --> badness ensues. Family sues for not calling surgery to be ready to do a surgical airway.

I could certainly be off base here, but I can't imagine a different service that should have been consulted in a complex airway situation.

 

[emergentmd]

Anesthesiologist here. Current ER group we have is awesome. When they call for help (very very rarely) I always know it will be something really bad.
Last ER group was clinically weak called us a lot for Tubes and central lines.

I am all in on this. I worked in the Pit for 15 years and Called anesthesia to help with intubation a total of 3 times for help so when I call, they know they need to drop almost everything.

I have called them zero times for central line help. I called them alot for blood patches but the pt can wait for as long as it takes them to come.

 

[thegenius]

I can’t for the time being, unfortunately.

Oh lord, not another one. I'm sorry hang in there.

 

[Groove]

This is not meant to be a pissing match between the two specialties regarding who is better at airway management (there are prior threads in both forums about this).

Lets say hypothetically you work at a hospital that has 24/7 anesthesia in house, and they are available and willing to respond to the ED.

Under what circumstances are you calling, if any?

Personally, I have too much respect for my anesthesia colleagues to "scut" them out for glorified ER MRT codes just because the hospital has managed to rope them into those duties. I've never worked at a hospital where gas routinely responds and/or is available to the ER 24/7 including major trauma centers. I interviewed at one job in CO that was a level 2 where anesthesia was on "stand by" for critical cases but wouldn't intubate unless you needed them, but that's only place I've ever seen with that policy. Maybe it's more common in different regions. I think if I was an anesthesiologist looking for jobs, I'd avoid the hospital you're excessively on call to the ED.

At this point in my career, I don't really have an ego anymore or at least it's a rabidly deflating ego. I know we've had some back and forth threads in the past between gas and EM but I honestly think of these guys as brethren more than other fields and look...they do have more airway experience, period. It's extremely rare for me to call for help with an airway but it happens. Whether it's pulm/ent/anesthesia/surgery, every body brings their own unique set of skills/experiences to the table and I've always found that valuable. Medicolegally, I doubt you'd be on the hook with anything that would ultimately stick in a lawsuit since you are technically trained to handle airway emergencies and it's totally within your specialty training (not to mention that most bad cases evolve rapidly before anyone is usually available). However, sometimes you just have a tough case and need a second pair of eyeballs and there's absolutely nothing wrong with that. It's not a sign of weakness but of maturity and experience. Sometimes, you pick up very neat tricks. I was talking to a colleague describing a pharyngeal mass and hairy airway case where ENT was called down and poked a 0 silk suture through the frenulum midway up the tongue between the labial arteries and through the top and made a loop and used that for traction and to manipulate the tongue to maximize view and was able to subsequently intubate. I'd have never thought of that.

I do agree with one of your other posts that during training...residents should be pushed to handle all airways as much as possible but agree that it can lend to a feeling of weakness when you are brand new, green and feel as if you should be able to handle everything by yourself. There's never any shame in asking for help.

Here's a good test. If I was a patient, s/p ACDF with a rapidly expanding hematoma in my neck comprising my airway and they rushed me into the ER and I had a choice between the EM attending or the anesthesiologist on call performing the intubation. Who would I call? Who would you call? If I'm honest with myself, and both were available in a timely manner, I'd probably ask for the anesthesiologist if I'm being honest with myself.

 

[Groove]

I can actually remember one case during residency where the attending called anesthesia for a crashing angioedema case and he did a nasotracheal intubation faster than I could blink. It was very smooth and he was very calm. There was absolutely nothing to see on the monitor except saliva and horribly edematous anatomy with absolutely no landmarks. He asked one of the residents to rapidly push on the chest and some bubbles started forming and he speared the scope to that point and somehow made it into the trachea and rammed the ETT home. I was a PGY2 or so and still think that was the right call in hindsight. If we hadn't been able to tube them, it would have turned into a very messy cric. Let's face it, these guys do way more of these kinds of cases than we do though I will admit that our training is generally very good.

 

[Kryptocoin]

We are trained to be experts in airway mgmt because most of us will work in hospitals without 24hr backup.
Airway emergencies are truly humbling but can be the most rewarding parts of our job. I've performed a cric twice in my career. Pretty gruesome but lifesaving. Both patients are alive and well today.

After 10yrs of practice, I've never had to call anesthesia. Not out of pride, but because they're usually staffed by CRNAs where I work and I've had bad experiences with them in the past.

 

[thegenius]

Here's a good test. If I was a patient, s/p ACDF with a rapidly expanding hematoma in my neck comprising my airway and they rushed me into the ER and I had a choice between the EM attending or the anesthesiologist on call performing the intubation. Who would I call? Who would you call? If I'm honest with myself, and both were available in a timely manner, I'd probably ask for the anesthesiologist if I'm being honest with myself.

God forbid, if I were in the ER as a patient and needed to be emergently intubated, and I was able to have a say in it, I would demand anesthesia do it. I've written this many times in the past. I would even say "if I live, I'm looking back in the chart to see who intubated me and will call a lawyer if it's not anesthesia!"

 

[LostinLift]

Called anesthesia for a rapidly progressing angioedema this past year. It ended up being a relatively easy bougie-tube and neck was marked and ready but I would rather have a second, more experienced pair of hands available if possible and avoid a cric. If they're available and it's a high risk airway I will call them. He had to drive 10 minutes in, watched for 45 seconds as I laid out the plan and did it, and drive 10 minutes home. For a high risk airway, saving a cric and/or patient's life, seems well worth it.

 

[Janders]

We only have daytime anesthesia in-house, and sometimes they are all pretty darned busy.

In a decade, I’ve called twice for angio-edema (once at night, forcing a very angry conversation… until the guy drove in, we got the tube together, and he apologized for being an ass and we shock hands friends). I think, especially when you are solo-coverage, and may have limited access to toys like fiber optic scopes, it’s VERY reasonable to ask anesthesia or someone to help with bad angioedema. The other was a daytime angioedema and me, the intensivist, the CRNA and the anesthesiologist all sat at the foot of the bed nodding and stroking our beards. Patient ended up rather rapidly improving so we didn’t intubate.

The other case I can recall was a post-op carotid who had a rapidly expanding hematoma (from OSH, of course) w/ voice change. I called vascular, and anesthesia, and the OR desk to try and make this go to the OR rapidly. Vascular came down and was like YEAH BUDDY LETS GO and ran off to the OR to get it ready. Anesthesia walked in, shrugged their shoulders, and left. Said they’d see the patient in the OR. I said… uh… his voice keeps getting worse… shouldn’t we tube him now? They said if you want to, go for it. And left.

So I got my meds and glidescope and the surgical PA hung out with me, and we were about to RSI when the vascular surgeon walked in, and had a class 7 conniption fit that anesthesia had left… anesthesia got to do this tube, in the OR, with the neck prepped.

But anyway, the answer is always do what it is right for the patient, and if that is CALL FOR HELP then you should have the pride in your professionalism to call for help!

 

[Mount Asclepius]

We pretty much always intubate severe angioedema either in the ED or the OR. Most mild to moderate angioedema improves pretty quickly with medications. Has anyone ever had a patient with angioedema occlude their airway? I’m just curious if it actually has happened, or do we perhaps intervene unnecessarily a lot of the time. We may never know. I fully concede that we will probably keep doing what we do as intubation is a much better option than seeing someone occlude their airway and respiratory arrest or end up with a cric. I’m just curious.

 

[PianoMedic]

We pretty much always intubate severe angioedema either in the ED or the OR. Most mild to moderate angioedema improves pretty quickly with medications. Has anyone ever had a patient with angioedema occlude their airway? I’m just curious if it actually has happened, or do we perhaps intervene unnecessarily a lot of the time. We may never know. I fully concede that we will probably keep doing what we do as intubation is a much better option than seeing someone occlude their airway and respiratory arrest or end up with a cric. I’m just curious.

Not exactly entirely closed up but I got the tube in just in time. Had a patient come in with a sore throat as a 3rd year resident. Put into a pod that didn’t have a doc on yet but they would have arrived within five minutes. Nurse goes in the room and immediately comes back out asking for a doc. My attending was assisting evaluation of a different patient with respiratory distress and so I went to see what the issue was. I walked in and tongue was asymmetrically swollen, left side. Uvula edema on the left, inferior to mandible on the left with brawny edema. Hot potato voice. When did it start? Less than 15 minutes before. Nurse was already gathering pharmacist with RSI kit, difficult airway cart and glidescope, while another got a line after giving 0.5 mg IM epi and the other anaphylaxis meds while I did my quick 15 second exam and then started setting up to tube. Hit the call light and asked them to page ent and anesthesia stat to bedside for a bad airway. Had someone grab my attending (that other one just needed bipap). He gets in there as I’m finishing set up. Less than 2 minutes to get all that done (we had tons of hands, early morning a bit after shift change). Tongue now completely edematous, uvula diffusely swollen and now we have stridor. I asked my attending if we should try to topicalize and do an awake fiber optic, “do you really think we have time for that?” Me: “no, you’re right let’s just go”. Etomidate then made sure I could ventilate her and then they gave the roc. Had scalpel in my pocket, bougie out with a 6.0 tube and we all talked through what would happen if I couldn’t get the tube (cric) before the roc went in. Glidescope in and all I could see was epiglottis b/c it was enormous. It was filling almost all of her throat, heard literally half the room that could see the screen gasp. I could see just a tiny bit of black anteriorly, and by adjusting the scope slightly oblique to the vallecula I could just see a tiny piece of white cord next to the black. Put the tube right there as fast as I could and advanced it just before the epiglottis closed over the black. Fastest progression of angioedema I’ve ever had. The resident and attending for that pod arrived to bedside just after tube went in. Ent arrived in the ED as I walked back to my desk. Anesthesia called back after I was at my desk. Front door to tube was less than 15 minutes. Sometimes we’re all the patient gets unfortunately. Patient was on lisinopril fwiw, I’ve had plenty that haven’t needed anything, tubed a handful of others. This was the worst and fastest. Almost never had the anaphylaxis meds work for angioedema, nearly all of mine are from ace-inhibitors. Sent some home that were self limited after watching for several hours and really only involved the lip(s). Maybe we’re over aggressive sometimes as the forced to act cases typically came in in duress for me, but I’d hate to have someone get a cric or code because I slow pedaled them for too long and then couldn’t get the tube.

 

[BoardingDoc]

We pretty much always intubate severe angioedema either in the ED or the OR. Most mild to moderate angioedema improves pretty quickly with medications. Has anyone ever had a patient with angioedema occlude their airway? I’m just curious if it actually has happened, or do we perhaps intervene unnecessarily a lot of the time. We may never know. I fully concede that we will probably keep doing what we do as intubation is a much better option than seeing someone occlude their airway and respiratory arrest or end up with a cric. I’m just curious.

My last one had completely occluded her airway via her mouth but was still able to breathe with difficulty via her nose when I did a FO Nasal tube. Her husband said she took benadryl when the swelling started 10-15 min ago. The fact that she could swallow anything so recently was amazing as her tongue literally had expanded to fill her entire mouth and a swollen mass of tongue meat was protruding from her mouth about an inch. Given that the tongue was expanding outward, I can only assume that it would have continued expanding backwards and occluded her airway had we not done something.

Also, in her case, she 100% needed to be intubated for airway protection as literally the only place that vomit could go was either back down to stomach, lungs, or out the nose. Easily the scariest tube of my life.

And yes, I had anesthesia at the bedside with me for that one and had already prepped the patient's neck. While I was the one holding the scope, it was very much a two doc show.

 

[Janders]

I’ve seen a few dozen cases of angioedema. I’ve seen… 5-10 that appeared scary. I’ve intubated just one (mentioned up thread). She came with a fully occluding tongue, sticking out of her mouth, jaw open but teeth still deeply indenting tongue. Unable to visualize any posterior structures. She didn’t feel as if her throat was swollen on arrival, so we did the meds and started to topicalize her and called in anesthesia about 5 minutes later when she said she was feeling her throat close. By the time we made our move a few minutes later, she was tripodding and basically jaw-thrusting herself to keep things open, with intermittent stridor. Yuck.

So the VAST VAST majority seem to settle out on their own. But once in a while…

 

[The Knife & Gun Club]

Not exactly entirely closed up but I got the tube in just in time. Had a patient come in with a sore throat as a 3rd year resident. Put into a pod that didn’t have a doc on yet but they would have arrived within five minutes. Nurse goes in the room and immediately comes back out asking for a doc. My attending was assisting evaluation of a different patient with respiratory distress and so I went to see what the issue was. I walked in and tongue was asymmetrically swollen, left side. Uvula edema on the left, inferior to mandible on the left with brawny edema. Hot potato voice. When did it start? Less than 15 minutes before. Nurse was already gathering pharmacist with RSI kit, difficult airway cart and glidescope, while another got a line after giving 0.5 mg IM epi and the other anaphylaxis meds while I did my quick 15 second exam and then started setting up to tube. Hit the call light and asked them to page ent and anesthesia stat to bedside for a bad airway. Had someone grab my attending (that other one just needed bipap). He gets in there as I’m finishing set up. Less than 2 minutes to get all that done (we had tons of hands, early morning a bit after shift change). Tongue now completely edematous, uvula diffusely swollen and now we have stridor. I asked my attending if we should try to topicalize and do an awake fiber optic, “do you really think we have time for that?” Me: “no, you’re right let’s just go”. Etomidate then made sure I could ventilate her and then they gave the roc. Had scalpel in my pocket, bougie out with a 6.0 tube and we all talked through what would happen if I couldn’t get the tube (cric) before the roc went in. Glidescope in and all I could see was epiglottis b/c it was enormous. It was filling almost all of her throat, heard literally half the room that could see the screen gasp. I could see just a tiny bit of black anteriorly, and by adjusting the scope slightly oblique to the vallecula I could just see a tiny piece of white cord next to the black. Put the tube right there as fast as I could and advanced it just before the epiglottis closed over the black. Fastest progression of angioedema I’ve ever had. The resident and attending for that pod arrived to bedside just after tube went in. Ent arrived in the ED as I walked back to my desk. Anesthesia called back after I was at my desk. Front door to tube was less than 15 minutes. Sometimes we’re all the patient gets unfortunately. Patient was on lisinopril fwiw, I’ve had plenty that haven’t needed anything, tubed a handful of others. This was the worst and fastest. Almost never had the anaphylaxis meds work for angioedema, nearly all of mine are from ace-inhibitors. Sent some home that were self limited after watching for several hours and really only involved the lip(s). Maybe we’re over aggressive sometimes as the forced to act cases typically came in in duress for me, but I’d hate to have someone get a cric or code because I slow pedaled them for too long and then couldn’t get the tube.

What does brawny edema actually look like and hot potato voice sound like?

Ive yet to hear anything that makes me think “ah yes, this is the “hot potato voice” I’ve been waiting for for 10 years.

 

[TheComebacKid]

What is the utility to RSI in angioedema? I feel like having them spontaneously breathe is literally the only thing they have going for them and RSI is taking them even closer to COCV scenario.

If you go the route of topicalization, it will take awhile, but if you can get in a scope and at least take a quick look you can and determine if they need to be intubated or are even intubatable from above.

I will say, despite what people say, I find some patients really struggle to cooperate with fiberoptic and it can set you back.

 

[HoosierdaddyO]

I’ve honestly found this approach to be quite helpful… if you sit the patient upright and you take your glidescope, and if you turn it upside down as if you’re using it as a tongue depressor. While the patient is awake and breathing and conscious it allows you to get a semi decent look at the posterior oropharynx… all the while not having to lay the patient flat, not having to sedate or paralyze the patient and this is an amazing tool to help just visualize what’s going on back there. I’m not saying this is how you intubate. But I have found that fiberoptic can indeed make matter worse, patients can sometimes acutely decline when fiber optics are used. So I found this inverse/upside down, while sitting up approach coming at them from the front has been helpful many times to Gauge the airway 😊!!!

 

[BoardingDoc]

What is the utility to RSI in angioedema? I feel like having them spontaneously breathe is literally the only thing they have going for them and RSI is taking them even closer to COCV scenario.

If you go the route of topicalization, it will take awhile, but if you can get in a scope and at least take a quick look you can and determine if they need to be intubated or are even intubatable from above.

I will say, despite what people say, I find some patients really struggle to cooperate with fiberoptic and it can set you back.

Agree about RSI being counter to what I'd do unless it wasn't severe angioedema. I did my IN tube as follows:
- Patient bolt upright.
- Face mask on patient nebulizing lido
- Serial nasal dilation with nasal trumpets. Small trumpet coated in lidocaine jelly. Leave in for a minute, then replace with the next size up, each one coated in lido jelly until you have it big enough that a 6.0/6.5 tube fits in the nostril (I don't remember which size ETT I used).
- Lido jelly lube up the tube and insert it into the nose until it has just turned the corner and then leave in place
- Insert FO scope through tube in nose and figure out where I'm gonna go.
- Give ketamine
- Pass tube.

I also had concerns about how she was going to do with cooperating for the FO look. I had plans to give a couple mg of versed IV if needed, but ultimately she had no issues with it.

 

[turkeyjerky]

What is the utility to RSI in angioedema? I feel like having them spontaneously breathe is literally the only thing they have going for them and RSI is taking them even closer to COCV scenario.

If you go the route of topicalization, it will take awhile, but if you can get in a scope and at least take a quick look you can and determine if they need to be intubated or are even intubatable from above.

I will say, despite what people say, I find some patients really struggle to cooperate with fiberoptic and it can set you back.

I think the main utility of RSI in this situations is in a 'forced to act' scenario where you don't have time for topicalization and airway loss is likely to be imminent. If you only expect to have once chance, you want it to be optimized as much as possible.

I also think RSI is reasonable if you are in a small hospital and have a patient who presents early but w/ progressive symptoms, in which case you want to secure the airway before a prolonged transfer.

 

[PianoMedic]

What does brawny edema actually look like and hot potato voice sound like?

Ive yet to hear anything that makes me think “ah yes, this is the “hot potato voice” I’ve been waiting for for 10 years.

Sorry, to me-brawny edema feels like that deep cellulitis (with the indurated skin and angry erythema), but the skin is totally normal appearing. It’s really firm cuz there is so much fluid in the tissue, it doesn’t pit in the slightest. Super tense and taught. Hot potato voice for me is easier to hear than explain but I’ll try-think about like terrible laryngitis voice that you initially think is raspy, but then you realize there isn’t any of that airy quality to it. It’s then having to force air through their vocal chords, so they are sitting weird and taking big breaths before they try to talk. And it all comes out in a row as the breath exhales. That probably isn’t much help sorry. It’s a “you’ll know it when you hear it” thing unfortunately.

 

[PianoMedic]

Agree about RSI being counter to what I'd do unless it wasn't severe angioedema. I did my IN tube as follows:
- Patient bolt upright.
- Face mask on patient nebulizing lido
- Serial nasal dilation with nasal trumpets. Small trumpet coated in lidocaine jelly. Leave in for a minute, then replace with the next size up, each one coated in lido jelly until you have it big enough that a 6.0/6.5 tube fits in the nostril (I don't remember which size ETT I used).
- Lido jelly lube up the tube and insert it into the nose until it has just turned the corner and then leave in place
- Insert FO scope through tube in nose and figure out where I'm gonna go.
- Give ketamine
- Pass tube.

I also had concerns about how she was going to do with cooperating for the FO look. I had plans to give a couple mg of versed IV if needed, but ultimately she had no issues with it.

Thank you for this write up. I’ve only ever seen people teach and describe awake NT fiber optic being done with the tube on the scope until you see the cords, then advance. I like your method much better where the tube is into the nose but not all the way in and then steering it in the rest of the way with the scope.

Agree with turkeyjerky’s writeup above re: why RSI in some of these situations. The “forced to act” scenario is extremely rare in medicine, we are the ones who see it more than most specialties I think. Another big key is not taking a quasi stable situation and making it a forced to act situation. I didn’t like laying my patient back and doing RSI. But with the stridor starting and her rapidly progressing edema, we were very worried that her vocal cords or arytenoids were swelling. Turns out it was epiglottis. Our nursing staff/techs are good at setting up for traditional RSI. Setting up for an awake FO would take us a decent amount longer to find the correct lido and get from the Pyxis plus getting all of the other equipment to bedside.

Hoosierdaddy gives a good idea to assess the airway. I would also say you could try intubating this way if you had to rapidly ie the tomahawk method. Very much not ideal. But it can allow someone to keep maintaining an airway that would become unstable laying back or that doing an awake FO isn’t an option on (massive facial trauma maintaining airway sitting up with copious bleeding that is likely to obscure your FO). These should be rare hopefully.

 

[TheComebacKid]

I have had very little success with nebulized lidocaine. I don't think it does anything. I think atomized lidocaine is a bit better. I use both now. I've had patients snort up lidocaine jelly and that works probably the best.

As a resident I did a two week elective in ENT clinic where I got to do a bunch of scopes, granted these weren't in crashing/sick patients, however they pretty much never topicalize and patients tolerate it fine.

For me the issue with fiberoptic is less about the time it takes to topicalize, but rather whether you can coax a somewhat anxious/sick patient who feels like their airway is about to close to cooperate with the procedure. I am not a fan of giving these people any sedation because I think it makes the procedure harder. I'll push the ketamine +/- paralytic once I am in the trachea.

Fiberoptic is critical for a variety of reasons, but even if you choose to go down the RSI route, I still think you should do fiberoptic to get a look at the airway first. What if they can't even be intubated from above... then you will be in a whole world of trouble if you RSI them. A pediatric scope is so easy to use to get a quick look at the airway, assuming you have it, and you may not even need to topicalize.

I get it's a hail mary scenario and if you don't have fiberoptic or they are crashing you want to optimize your chances so you use RSI. That being said, my number 1 goal is to maintain spontaneous respirations and not use paralytic and THEN secure the airway. I think the patient would have a better outcome if you did ketamine + surgical airway first as opposed to pushing the paralytic and not being able to bag them if you can't get the tube with VL/DL and then proceeding to surgical airway.

 

[wook]

At this point in my career, I don't really have an ego anymore or at least it's a rabidly deflating ego. I know we've had some back and forth threads in the past between gas and EM but I honestly think of these guys as brethren more than other fields and look...they do have more airway experience, period. It's extremely rare for me to call for help with an airway but it happens. Whether it's pulm/ent/anesthesia/surgery, every body brings their own unique set of skills/experiences to the table and I've always found that valuable.

This....

Also, in my mind it's about the patient. I feel very comfortable intubating, but if there is a possibility of alot of excitement, I may have them come downt to back me up. I think I've done this 4 times in 10 years. Medicine is a team sport, and if having another set of hands improves the patient outcome, I'm glad to have their support.

 

[DrOwnage]

Agree about RSI being counter to what I'd do unless it wasn't severe angioedema. I did my IN tube as follows:
- Patient bolt upright.
- Face mask on patient nebulizing lido
- Serial nasal dilation with nasal trumpets. Small trumpet coated in lidocaine jelly. Leave in for a minute, then replace with the next size up, each one coated in lido jelly until you have it big enough that a 6.0/6.5 tube fits in the nostril (I don't remember which size ETT I used).
- Lido jelly lube up the tube and insert it into the nose until it has just turned the corner and then leave in place
- Insert FO scope through tube in nose and figure out where I'm gonna go.
- Give ketamine
- Pass tube.

I also had concerns about how she was going to do with cooperating for the FO look. I had plans to give a couple mg of versed IV if needed, but ultimately she had no issues with it.

This is a good technique. One of the ways I learned in anesthesia residency. Another trick is to take a pair of scissors and cut a line down the last nasal trumpet you need (it will still go down the nose). Then you can stick the lubed endotracheal tube down the nasal trumpet, then fiberoptic through the tube. Once you get the tube in, you can just pull the nasal trumpet out and it will split off the tube.

There's also another cool way to do this nasotracheal awake if you have a ventilator, ETCO2 and a bronch swivel adaptor.

 

[GassYous]

Agree about RSI being counter to what I'd do unless it wasn't severe angioedema. I did my IN tube as follows:
- Patient bolt upright.
- Face mask on patient nebulizing lido
- Serial nasal dilation with nasal trumpets. Small trumpet coated in lidocaine jelly. Leave in for a minute, then replace with the next size up, each one coated in lido jelly until you have it big enough that a 6.0/6.5 tube fits in the nostril (I don't remember which size ETT I used).
- Lido jelly lube up the tube and insert it into the nose until it has just turned the corner and then leave in place
- Insert FO scope through tube in nose and figure out where I'm gonna go.
- Give ketamine
- Pass tube.

I also had concerns about how she was going to do with cooperating for the FO look. I had plans to give a couple mg of versed IV if needed, but ultimately she had no issues with it.

Nebulized lido is garbage and takes too long.

Lido 2% and neo mixed together. A few ccs in each nostril. Scope in, lido on cords. Wait a bit then scope in. Tube in.

 

[Groove]

I take a bottle of afrin and squirt out about half the bottle and take a syringe with small gauge needle and put in some lidocaine 4% through the atomizer port. (If you use a large gauge needle it will dilate the hole and you lose the atomizing effect). Shake it up and squirt. Works really well. I picked it up from an ENT doc years ago. Touch of cetacaine or hurricaine spray in the throat. I've never had much luck with nebulized lido and any positive effect required lengthy nebulization which kind of defeats the purpose since most of the time there is a sense of urgency if we're considering AFOI in the ED.

I like the cutting the nasal trumpet trick as well as mixing Neo with the lido. I'll have to try those next time.

 

[Dr Mantis Toboggan]

Nebulized lido is garbage and takes too long.

Lido 2% and neo mixed together. A few ccs in each nostril. Scope in, lido on cords. Wait a bit then scope in. Tube in.

Um, little too much actual medicine in this thread. This forum is exclusively for bemoaning how bad we have it and how grim the future of the specialty is…

 

[coffeebythelake]

What is the utility to RSI in angioedema? I feel like having them spontaneously breathe is literally the only thing they have going for them and RSI is taking them even closer to COCV scenario.

If you go the route of topicalization, it will take awhile, but if you can get in a scope and at least take a quick look you can and determine if they need to be intubated or are even intubatable from above.

I will say, despite what people say, I find some patients really struggle to cooperate with fiberoptic and it can set you back.

If your RSI a severe angioedema who you could have done spontaneous breathing you better be able to intubate otherwise open the checkbooks.

 

[MechEDoc]

I usually call from a risk management perspective. If there is the potential for a very difficult airway or a high risk airway (e.g. neonate), then I call. I view it as appropriately using resources to have them on standby should things go badly. I would rather get flack for calling and colleagues and ultimately not having them needed versus not using a colleague and having a case go badly. Even if the patient is predestined have a bad outcome, it would be better to do so after exhausting all resources.

 

[alpinism]

I'm sorry but to be honest this is pretty weak for a residency trained EM specialist.

Not sure where any of you trained but I was trained to be an expert in difficult emergency airways. I don't call anesthesiologists for tubes which has nothing to do with my pride or arrogance. I don't call them because it's literally my job to manage these airways. I treat every airway like its the worst case of angioedema I've ever seen and have extensive training in performing all types of intubation techniques including everything from oral to nasal to anterograde to retrograde tubes plus I also have the ability to do surgical airways such as crics and trachs if needed.

 

[HoosierdaddyO]

Yea that’s nice that you’re a professional airway guru, but so is Anesthesia and I’m cool with being part of a team if that team is available specifically for situations like this. But if your hospital has a critical air way team… and you have a critical airway. And in the off chance something does go wrong and you don’t call the team, why open yourself up to all that liability. Sounds like ego more than anything else. If you ever had an airway go south for no fault of your own… it’s nice to know and have other specialists be there and all concur that it was a messed up case, just seems smart to do in a world of litigation and liability!!!

 

[TheComebacKid]

I'm sorry but to be honest this is pretty weak for a residency trained EM specialist.

Not sure where any of you trained but I was trained to be an expert in difficult emergency airways. I don't call anesthesiologists for tubes which has nothing to do with my pride or arrogance. I don't call them because it's literally my job to manage these airways. I treat every airway like its the worst case of angioedema I've ever seen and have extensive training in performing all types of intubation techniques including everything from oral to nasal to anterograde to retrograde tubes plus I also have the ability to do surgical airways such as crics and trachs if needed.

It doesn't matter where you trained, or how much skill you have. We are talking about the 0.001% of airways that are truly the most difficult airways there are. In that case, there is absolutely literally ZERO downside to having help from someone who has intubated probably 10x as many patients as you.

Nobody is arguing that you should let your airway skills lapse, become complacent and call in anesthesia for every airway. It's great that you know all these techniques, and very may well have to use them since anesthesia is not readily available in most shops. But if you do work at a place that does have some support, I think not utilizing additional resources in these particularly horrible airway scenarios only does the patient a disservice.

It's your job to be really good at EKGs. Never called a cardiologist to help you look at one that was a head scratcher?

 

[coffeebythelake]

I treat every airway like its the worst case of angioedema I've ever seen

If that's true you would be doing awake intubations or surgical airway on every patient.