Can oxygenate and ventilate at single doc hospital

[EDL and mast cells]

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I had an obese woman come in unresponsive and hypoxic with copious emesis in mouth. I RSI and can’t see anything with VL and suctioning x2. Able to place standard LMA. Sats stable again. Try DL and able to pass tube. This was a shift at a smaller hospital with no ICU or anesthesia. I was thinking if for some reason I just couldn’t get her intubated but the LMA was working, what would be the reasonable thing to do in that circumstance? Keep the LMA in place while attempting a cric and don’t transfer to other hospital until cric’d? or just transfer with LMA in place until arrival to tertiary facility with anesthesia? Obviously the LMA wouldn’t be ideal with the vomit and aspiration etc. and it’s not a definitive airway, but I don’t think this lady’s neck would have been an easy cric and we were still able to effectively oxygenate and ventilate.

 

[HoosierdaddyO]

BOUGIE… otherwise LMA (secure it as best as could be) and sit up at 45 degrees to decrease aspiration risk. I wouldn’t cut the neck on a patient that big. Especially if they are for the most part maintaining sats. It sounds like a no win situation if you couldn’t get the hypothetical tube.

Last resort would be a nasal intubation!

 

[southerndoc]

The last time I had an obese patient I couldn't intubate, I used a central line kit, inserted the needle opposite you would expect (I inserted aimed at the head), punctured the cric membrane, fed a central line guidewire tube out, fished it out with McGills using direct laryngoscopy, and then intubated her. I got kudos from my colleagues, but I often wondered if it would've been quicker to just have cut the darn neck.

 

[HoosierdaddyO]

The last time I had an obese patient I couldn't intubate, I used a central line kit, inserted the needle opposite you would expect (I inserted aimed at the head), punctured the cric membrane, fed a central line guidewire tube out, fished it out with McGills using direct laryngoscopy, and then intubated her. I got kudos from my colleagues, but I often wondered if it would've been quicker to just have cut the darn neck.

Haha aight there Dr. Pitt (there was an episode where they did that). And I remember saying to myself there’s no way in hell that I’m doing that let alone on an obese patient😂! Kudos to you if you feel comfortable tho lol.

 

[turkeyjerky]

The last time I had an obese patient I couldn't intubate, I used a central line kit, inserted the needle opposite you would expect (I inserted aimed at the head), punctured the cric membrane, fed a central line guidewire tube out, fished it out with McGills using direct laryngoscopy, and then intubated her. I got kudos from my colleagues, but I often wondered if it would've been quicker to just have cut the darn neck.

Why not just say you rid a retrograde wire?

 

[southerndoc]

Why not just say you rid a retrograde wire?

The last time I posted about it during my Facebook days, I had several people ask WTH I was talking about.

 

[RustedFox]

Those fenestrated LMAs?
Cut them with an 11 blade .
Feed a bougie thru it.
Works.
Failing that, do what SouthernDoc did.
Failing that, call @CajunMedic

 

[TooMuchResearch]

The last time I had an obese patient I couldn't intubate, I used a central line kit, inserted the needle opposite you would expect (I inserted aimed at the head), punctured the cric membrane, fed a central line guidewire tube out, fished it out with McGills using direct laryngoscopy, and then intubated her. I got kudos from my colleagues, but I often wondered if it would've been quicker to just have cut the darn neck.

They taught us this procedure as retrograde intubation in residency. We actually had kits for it in our rural facilities until some number of years ago when they all expired and only a few of us knew what the kit was for so I believe they stopped stocking them.

 

[TooMuchResearch]

The last time I posted about it during my Facebook days, I had several people ask WTH I was talking about.

Okay I didn't scroll down far enough.

 

[TooMuchResearch]

OP, depending on the supraglottic airway, you can potentially snake a bougie through it, pull supraglottic, then feed ETT over the bougie.

If you have disposable fiber-optic scopes, you can put one of those down, hold it, cut it at the base, and snake an ETT over.

Cric.

If you believe for whatever reason none of these are feasible, you can actually ventilate and oxygenate through the supraglottic, you have critical care transport, and it's not a very long transport, could consider transport with supraglottic in extreme situations.

 

[southerndoc]

They taught us this procedure as retrograde intubation in residency. We actually had kits for it in our rural facilities until some number of years ago when they all expired and only a few of us knew what the kit was for so I believe they stopped stocking them.

I wasn't taught it during residency. Was taught during paramedic school of all things.

 

[CajunMedic]

My first thought is place a bougie through the LMA and use that to intubate if you have the LMA's that allow it, If not. Ventilate with the LMA, most, if not all Paramedics are familiar with Supraglottic airways and a competent one, especially a critical care one, should be able to manage it during the transport. If it's working, don't mess with it. Depending on the situation, the retrograde wire-guided is a good choice, but based on her neck, might have been difficult

 

[Bittersteel]

Shyt your pants situation.

Thanks to the badazzes above for the tips.

 

[TeddyBoomBoom]

I can’t imagine cric’ing somebody that was being successfully oxygenated and ventilated by an LMA.

I acknowledge the difficult logistics of transferring without a “secured airway,” but I’m fairly certain a bad outcome from a failed
cric on a patient that was otherwise chillin with an LMA would be tough to defend.

 

[carbonizedeyesockets]

My first thought is place a bougie through the LMA and use that to intubate if you have the LMA's that allow it, If not. Ventilate with the LMA, most, if not all Paramedics are familiar with Supraglottic airways and a competent one, especially a critical care one, should be able to manage it during the transport. If it's working, don't mess with it. Depending on the situation, the retrograde wire-guided is a good choice, but based on her neck, might have been difficult

I agree. it's always important to remember that a patient won't necessarily die without an ET tube, but will without ventilation and oxygenation. If LMA or any supraglottic airway (or BVM) is working - let it be. Crics seem like they should be easy, but often are not. I know of numerous cases where they did not go well (one through thyroid cartilage another through the hyothyroid membrane). Pt lived in both cases, so it's still a win, but both required surgery to repair. And then theres the bloody mess and possibility of cutting yourself with a scalpel (cared for a surgeon that did this).

 

[Apollyon]

☝️ As I learned in EMS, "good BLS beats bad ALS 8 days a week".