Calling Anesthesia

[Cinclus]

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The amount of experience on this thread tubing awake or with fiberoptics puts me to shame. I have none of that stuff anywhere in my ER. I have DL, a bougie, glidescope, and that's it. I don't know what the F I would do if someone came into my ER with a tongue so swollen that it engulfs their entire mouth. That would be scary.

I know what I would do...and it would involve needing a new pair of scrub pants soon after. Also, I would be calling anesthesia to assist while having RT grab every airway adjunct available and making sure the trusty 11 blade is in my pocket.

 

[Arch Guillotti]

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.

I also score the nasal trumpet all the way down lengthwise however I only go through the nasal airway with the scope. 90% of the time I am looking straight at the cords when the scope exits the nasal airway. The other 10% of the time it just needs to be pulled back a bit. Squirt the cords/trachea. Remove nasal airway, drive scope, thread tube. The key to the whole endeavor is not to use a regular 6.0 ETT because it is barely long enough to get into the trachea, 6.0 nasal rae's are also weak. Use a 6.0 MLT. If you don't know what it is just google a picture and you will see that it is much longer than normal. Any decent anesthesia dept. will have them.

 

[TheComebacKid]

The amount of experience on this thread tubing awake or with fiberoptics puts me to shame. I have none of that stuff anywhere in my ER. I have DL, a bougie, glidescope, and that's it. I don't know what the F I would do if someone came into my ER with a tongue so swollen that it engulfs their entire mouth. That would be scary.

If I didn't have fiberoptic... and the patient was tripodding, drooling, hypoxic, looked bad, I would probably just go down the path of surgical airway.

Ketamine only intubation would never work, probably worsening whatever swelling they had. RSI would probably kill them. Controlled crich with a tiny bit of sedation is probably the best bet in my opinion.

And yes, I would be calling anesthesia, even in from home, to help assist.

 

[Janders]

If I didn't have fiberoptic... and the patient was tripodding, drooling, hypoxic, looked bad, I would probably just go down the path of surgical airway.

Ketamine only intubation would never work, probably worsening whatever swelling they had. RSI would probably kill them. Controlled crich with a tiny bit of sedation is probably the best bet in my opinion.

And yes, I would be calling anesthesia, even in from home, to help assist.

Yes, when I’ve worked without fiber optic (but with glidescope), at the moment when they start to lose their airway despite their best conscious effort (i.e. they are past tripodding, and are now getting agitated/clawing…)… you push induction ketamine OR RSI and give it one solid college try with your glidescope and your skillz, and then you slice neck.

The ONE time it’s come to that, anesthesia arrived as the patient turned the corner to “actively dying now” basically as they walked in, we pushed ketamine / propofol hoping they would still spontaneously breath a bit (meh, airway occluded once they relaxed and laid back at all…) and used all four of our hands to intubate (glide scope, tube on rigid stylet, extra operator on Yankeur as suction / “retraction”, extra hand on larynx moving it around to help achieve a view). We probably took nearly 60s from putting blade in mouth to getting tube through cords, and were actively discussing my aborting my helper role and picking up the scalpel when we achieved success.

 

[CoolDoc1729]

If I didn't have fiberoptic... and the patient was tripodding, drooling, hypoxic, looked bad, I would probably just go down the path of surgical airway.

Ketamine only intubation would never work, probably worsening whatever swelling they had. RSI would probably kill them. Controlled crich with a tiny bit of sedation is probably the best bet in my opinion.

And yes, I would be calling anesthesia, even in from home, to help assist.

I swear this thread jinxed me as the other day I see on my tracking board, #17 on the waiting room list, “tongue swelling” .. the clueless 6 weeks out of school triage RN had taken care of that one herself and put the lady back in the waiting room, the orienting nurse had stepped out of the room to do something … I walked out there to investigate and zero posterior oropharynx and also the aforementioned “hot potato voice” 😬 I put the glide and the cric tray in the only available ED room and begged the house sup for a bed , notified ent and anesthesia. The lady was vehement about not needing to be intubated and she was out of my dept in 45 minutes. I did not hear any “anesthesia stat” pages the rest of the night either. I’ll have to remember to gently “educate” the trainee triage nurse…

 

[alpinism]

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?

I mean in a perfect world every difficult airway patient would be arriving carrying a bright red sign and be obvious from across the room but we both know that isn’t true especially in the emergency department. If anything I’d say that some of the most difficult airways I’ve had looked relatively straight forward prior to attempting intubation. My point is that you can never really accurately predict every single patient that will ultimately end up becoming a difficult airway. In that case if you truly believe that calling anesthesiology is best for patients when you have a difficult airway then you should be calling them for every airway. The bitter truth is that in reality this is the exact same reason why some big name hospitals still require anesthesiology to respond for all trauma team notifications and supervise the intubation for all trauma team resuscitations.

 

[alpinism]

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

I may not always use the scope but its always right there at the bedside for intubations.

 

[Arch Guillotti]

I swear this thread jinxed me as the other day I see on my tracking board, #17 on the waiting room list, “tongue swelling” .. the clueless 6 weeks out of school triage RN had taken care of that one herself and put the lady back in the waiting room, the orienting nurse had stepped out of the room to do something … I walked out there to investigate and zero posterior oropharynx and also the aforementioned “hot potato voice” 😬 I put the glide and the cric tray in the only available ED room and begged the house sup for a bed , notified ent and anesthesia. The lady was vehement about not needing to be intubated and she was out of my dept in 45 minutes. I did not hear any “anesthesia stat” pages the rest of the night either. I’ll have to remember to gently “educate” the trainee triage nurse…

Did either service see the lady in the ER?

 

[CoolDoc1729]

Did either service see the lady in the ER?

Anesthesia cruised by but then they got stat paged to the covid floor 😬 and ent .. called back several hours later .. we don’t technically have ENT call coverage so if we’d needed a cric it would been me. Seems like she did ok.. thankfully