Clinical Case: ORIF Mandible

[CanGas]

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36 yo Male transferred from up north (innuit) with bilateral fractured mandible for jaw wiring.
5’ 220 lbs.
Prior tonsillectomy as a kid with no problems with GA.
Hx of Asthma as a kid but no puffers since, no ER visits or hospitalizations. 1 ppd smoker x 15 years.
No cardiac issues.
No GERD, bleeding issues.
NPO x 12 hrs.
Only med is Tylenol.

OE: slight decreased Air entry bilaterally, no wheezing. Normal heart sounds. Airway: poor dentition, only able to open mouth 1.5 cm due to pain. Pt states jaw does not lock, it just hurts.

Discussed awake fiber optic vs look and see. Staff decided to look and see.

In OR: std monitors. Otrivin nose drops bilaterally. #7.5 nasal RAE ETT placed in warm bottle of NS.

Pre-O2.

50 Fent
60mg Propofol

Jaw mobile with good opening. Easy bag mask.

+ 100 Fent
+ 100 Propofol
+ 80 Succinylcholine

Nasal RAE placed with some difficulty. Direct laryngoscopy with grade 1 view, some blood noted in posterior pharynx. McGill forceps to place ETT. Pass ETT through cords but tip keeps catching on anterior trachea and folds backwards. 3 attempts with same result. Attempt to grab ETT at tip and angle posteriorly to place, still unsuccessful. After total of 50 seconds pt begins to desat like crazy. 90 to 70% in 15 seconds.

Elect to abort but when remove ETT and attempt to BAG pt is very tight requiring high airway pressures. Sat now 60% and falling, not rising on 100% O2.

What do you do?

 

[ALTorGT]

Bronchodilator to relieve airway pressures?

 

[Noyac]

Oral intubation!

If unsuccessful, cut him for cricothyrotomy.

 

[Noyac]

Bronchodilator to relieve airway pressures?

He's desat'ing and will die b/4 bronchdilator has any effect.

 

[cubs3canes]

He's desat'ing and will die b/4 bronchdilator has any effect.

Still a newbee, but what about jet ventilation to increase the sats and buy more time, then do a video assisted oral intubation.

Probably wrong because the mouth will not open enough, but a guess none the less.

 

[2ndyear]

1. Pop in an LMA and at least ventilate/oxygenate for a while. Hope this overcomes the difficulty in masking him...

2.When the SpO2 has risen and he is adequately ventilated, put a smaller tube on a Bougie. You said he had a grade 1 view on DL, so the issue is with threading the tube.

I had a similar thing with a fiberoptic not too long ago. Easy to pass the scope, but 3 tries and the darn thing just wouldn't go through the cords. A 6.0 did work, however.

 

[pmichaelmd]

1. Pop in an LMA and at least ventilate/oxygenate for a while. Hope this overcomes the difficulty in masking him...

2.When the SpO2 has risen and he is adequately ventilated, put a smaller tube on a Bougie. You said he had a grade 1 view on DL, so the issue is with threading the tube.

I had a similar thing with a fiberoptic not too long ago. Easy to pass the scope, but 3 tries and the darn thing just wouldn't go through the cords. A 6.0 did work, however.

👍

 

[ThinkFast007]

👍

Newbie as well here..

assuming this is a larynospasm...would putting a LMA help? The seal isnt all that tight right?

well if the PPV doesnt work...how about giving sux (.25-1 mg/kg) to relax the laryngeal mxs..then try ventilating.

if not:
I say Transtrachea Ventilation (aka Cricothyrotomy) 😀 hooked up to a jet ventilator

OP, I bet your sympathetics were going nuts at this point!!

 

[InGasWeTrust]

DLx1, with your go to blade for oral intubation

If that fails, have surgeon with a 11 blade one swipe away on standby

Jam a LMA in, if the tube does not mist, tell surgeon to swipe!


Now change soiled scrub pants and call risk mgmt, if surgical airway

 

[Noyac]

I don't think an LMA will help in this case.
Sux has already been giving, but 80mg is not a whole lot in this 100kg pt, so muscle relaxant wouldn't hurt anything cause at this rate he ain't going to start breathing in time anyway. Jet vent is fine for rescue.

 

[toofache32]

assuming this is a larynospasm...would putting a LMA help? The seal isnt all that tight right?

well if the PPV doesnt work...how about giving sux (.25-1 mg/kg) to relax the laryngeal mxs..then try ventilating.

This is exactly what I was thinking. Sounds like laryngospasm.

I'm not sure why the tube would be "catching on the anterior trachea" after it passed the cords....the nasal rae tubes I've used are even curved posteriorly to lessen this possibility. I've done a ton of nasal intubations on mandible fractures and I haven't seen that yet. Not that that means anything. I would have considered removing the tube and "flexing" it for a better curvature if all that laryngospasm stuff wasn't in the picture.

Anyone use those BAAM Whistles for blind nasal intubations? It's a real slick way for mandible/midface patients still on c-spine precautions.

 

[toofache32]

If he was an "easy bag mask" after the Sux, as you said, I know some people who would just go ahead and give Vec (or something shorter acting) so you could once again own his airway and break out the toys, but I don't know if I would have the balls. Then again, if your alternative is a Cric, then I guess you're gonna be Vec'ing him anyway.

 

[Skrubz]

Oral intubation!

If unsuccessful, cut him for cricothyrotomy.

I agree with Noyac. Since there's now difficulty masking the patient, I'd just fall back to an oral ETT and secure the airway. Once you re-establish an airway and ventilate for a while (and maybe give some albuterol or just crank up the volatile), maybe consider a nasal fiberoptic (and watching yourself or someone else pull the oral ETT out before diving in with the fiber) if the surgeons are really pushing for a nasal tube.

It could be laryngospasm, but given the history of asthma (even if it's been quiescent) and tobacco hx, I'd also be thinking about bronchospasm from the airway irritation of the repeated intubation attempts.

 

[ThinkFast007]

I....

It could be laryngospasm, but given the history of asthma (even if it's been quiescent) and tobacco hx, I'd also be thinking about bronchospasm from the airway irritation of the repeated intubation attempts.

I know I was originially thinking laryngospasm, but yes given the h/o of asthma (per MnM) I think bronchospasm is more likely.

Does the guy having 'childhood' asthma and not active asthma give him a higher chance of hving bronchospams over laryngospasm?? Plus, i think like Noyac said you barely bronchodil would take some time to work and the guy's saturating at 60% so there's no time.....

what do i know i'm just a MSIV

 

[Idiopathic]

How about cut this patient for a cric right now? Why wait? I cant imagine wanting to orally intubate this particular patient and do you even want to waste the time with anything else?

I mean, Airway before Breathing, right?

 

[ThinkFast007]

How about cut this patient for a cric right now? Why wait? I cant imagine wanting to orally intubate this particular patient and do you even want to waste the time with anything else?

I mean, Airway before Breathing, right?

i think you are right about the airway before breathing...but.. I think they would rather that this pt not have a scar from a cric (although it probably wouldnt be that big) and I believe that having a cric will increase your chances of having subglottic stenosis later down the line (I saw this happen with a pt that had a previous trach. dude came in with subglottic stenosis and boy was it a mess).

putting aside the issue of cosmesis and possible subglottic stenosis, doing a cric will insure an airway, thus preventing death...

...I'm actually waiting on the OP to tell us the answer!

 

[Idiopathic]

Uh, yeah. If any of you guys ever: a) cant intubate me, b) cant bag me, and c) Im satting in the 60's...




Cut my f-in throat, force feed me bronchodilators down the airway. Ill take a scar.




Prevention of death is the key here in my eyes, not potential for subglottic stenosis (bad as that is).

 

[bubalus]

Sounds like you're basically at the can't intubate, can't ventilate portion of the ASA difficult airway algorithm (although you've never done an oral tube which could save your bacon if it would go in and you could ventilate through it). The algorithm would say an LMA is next. If inadequate or infeasible then emergency noninvasive (rigid bronch, combitube, TTJV), and if that doesn't work then cric/trach. I could cric him faster than I could get the jet ventilator in the room and set up, and a sat of 60 might push me in that direction.

If the TTJV worked, you could wake the guy up for an awake nasal fiber. If it didn't work, then you're getting really far up that proverbial body of water.

How about some epi for the bronchospasm while you're working on the airway?

 

[Skrubz]

Sounds like you're basically at the can't intubate, can't ventilate portion of the ASA difficult airway algorithm (although you've never done an oral tube which could save your bacon if it would go in and you could ventilate through it). The algorithm would say an LMA is next.

my line of thinking was that there seems to be a technical difficulty passing the nasal tube. i would definitely give an oral tube w/ a stylet a chance and if that one chance didn't work (i always have one off to the side ready to go, just in case), i'd go for the cric.

 

[tx082md]

In this case, I'm not sure how much a cric is going to help. If you are assuming with high pressures, you are dealing with bronchospasm; after you do the cric, you are still going to have the bronchospasm.

Since he was a grade I view, I would probably DL, put in the tube, Albuterol down the tube and ventilate.

Once you have secured the airway, then you can diagnose the cause of his high pressures impaired oxygenation.

 

[Idiopathic]

In this case, I'm not sure how much a cric is going to help. If you are assuming with high pressures, you are dealing with bronchospasm; after you do the cric, you are still going to have the bronchospasm.

Since he was a grade I view, I would probably DL, put in the tube, Albuterol down the tube and ventilate.

Once you have secured the airway, then you can diagnose the cause of his high pressures impaired oxygenation.

Now this guy has bilateral mandibular fx, does this affect your decision to DL/orally intubate?

 

[toofache32]

Now this guy has bilateral mandibular fx, does this affect your decision to DL/orally intubate?

The surgeons won't be able to operate with an oral tube, if that's what you're getting at, but we're just talking about keeping him from dying at this point. Otherwise, mandible fractures tend to provide great mobility of the anterior airway so you can maneuver them all around with the DL. But it was a grade 1 view anyway here.

 

[militarymd]

Just do regular intubation...fix problems...then reassess on how to put the tube back through the nose.

 

[Noyac]

The surgeons won't be able to operate with an oral tube, if that's what you're getting at, but we're just talking about keeping him from dying at this point. Otherwise, mandible fractures tend to provide great mobility of the anterior airway so you can maneuver them all around with the DL. But it was a grade 1 view anyway here.

Mandible fx's don't always give you good anterior movement or mobility. Many times these pts can't open their mouths due to pain and muscle spasm. You can induce them, paralyze them and still not be able to open their mouths at all, even when fully relaxed. I had a partner that always did awake FOB on these pts. Especially when the fx was more than 24 hrs old. He must have been burned at some time with this one. I don't go that far but I do make sure that they can open their mouths somewhat.

 

[toofache32]

Mandible fx's don't always give you good anterior movement or mobility. Many times these pts can't open their mouths due to pain and muscle spasm. You can induce them, paralyze them and still not be able to open their mouths at all, even when fully relaxed. I had a partner that always did awake FOB on these pts. Especially when the fx was more than 24 hrs old. He must have been burned at some time with this one. I don't go that far but I do make sure that they can open their mouths somewhat.

I guess I've had the opposite experience once they get paralyzed. Sometimes the bones get impinged and hang up on each other but I've always been able to just reduce them back into place during the DL. One exception is when the condyles (the "hinges") are fractured and/or displaced into the glenoid fossa.

I used to just go in blindly with a nasal rae with the right hand, hold the cricoid with my left hand and feel my way in. Turning the nasal rae 90 degrees and pushing the cricoid in the same directions usually did the trick. A BAAM whistle makes this much easier. But that's just my experience.

 

[militarymd]

I guess I've had the opposite experience once they get paralyzed. Sometimes the bones get impinged and hang up on each other but I've always been able to just reduce them back into place during the DL. One exception is when the condyles (the "hinges") are fractured and/or displaced into the glenoid fossa.

I used to just go in blindly with a nasal rae with the right hand, hold the cricoid with my left hand and feel my way in. Turning the nasal rae 90 degrees and pushing the cricoid in the same directions usually did the trick. A BAAM whistle makes this much easier. But that's just my experience.

what you describe is correct BEFORE swelling and inflammation sets in.

 

[ThinkFast007]

hey OP

what did you end up doing??

 

[CanGas]

Ok, sorry for taking a while to post what we did but I’ve been busy and still recovering from my last call (heart transplant, 2 kidney transplants and a kidney+pancreas transplant– woo hoo for training in a tertiary center!)

So to summarize where we are at: we now are approaching/are in a can’t intubate/can’t ventilate situation. Top of our list was bronchospazm 2nd to underlying asthma +/- aspiration of bloody secretions, we were also considering larnygospazm, allergy, and even the weird and wonderful MH.

While we sent a nurse to get the trach set, chricothyrotomy set and have the Oral and Maxiolofacial surgeons scrub I made an attempt to intubate orally. My problem intubating nasally was not in visualizing the cords but in passing the tube using the forcepts. I believe this was because the tube and been sitting for some time in the hot saline and became overly soft, it was catching on the anterior aspect of the trachea and folding over itself. The guy was hopefully on the wake-up end on the minor dose of propofol and Sux and I did not want to dig a bigger hole with more drugs so I grabbed a 7.5 styleted ETT and applied a judicious dose of brutane (sorry to whoever I stole that from) and easily fired the tube in.

Ventilation was tight with an end tidal CO2 in the low 60’s, a very steep CO2 curve, peak inspiratory pressures in the 40’s and prominent wheezing throughout all lung fields which fit with our bronchospazm picture. 100% O2, cranked up the Sevo to 3%, gave 6 puffs ventolin through the tube and a dose of steroids. Sat came up from a low of 62% to 99% over 1 min. Over the next 10 min airway pressures dropped into the 20’s and the wheezing improved. We then gave Lido 1mg/kg, woke the patient up and extubated uneventfully. Transferred to recovery where we gave him Ventolin and Atrovent nebs and gave him 3 hrs to settle. After the 3 hrs pt had sat 99% on 3L O2, good AE bilaterally and no wheezing with a normal ABG. We gave him another Neb of Ventoline and took back to the OR (yes I read the thread about how pre-emptive Ventolin does nothing but it made us feel better).

In the OR topicallized the other nare with Otriven type vasoconstrictor and lido jelly. Performed an easy awake FOB intubation and the surgery proceeded on Sevo + narcotics. No bronchoconstriction was noted this time.

At the end of the surgery the patient was kept intubated and sedated for 6 hrs in Recovery and extubated 1st thing in the morning uneventfully.

So what happened earlier?

What I think happened was that the guy has a baseline level of asthma that was not controlled as the pt had no primary care. The nasal attempt failed 2nd to an overly malleable tube that would not thread straight and the trauma/blood/secretions injected into the trachea during the intubation attempt/bag mask after resulted in bronchoconstriction.

I think we handled it right by tubing him orally and then waking him up when stable. Did we do the right thing in taking him back 3hrs later vs trying to further optimize and bring back at a later date? Well I don’t know how long it would have taken to further optimize his asthma and he looked pretty good at the time. The numbers and the patient looked good and the event could be explained by transient bronchoconstriction from minor aspiration of blood/secretions. Why delay if you really aren't going to do anything different?

Comments?

 

[Tenesma]

dude... this happens all the time w/ nasal rae that are warmed up too much and get too soft at the end...

when i see the tip flip back there are 4 easy fixes
1) you already have the fiberoptic in the room because you anticipated difficulty - so you glide the fiberoptic through the RAE advance through the cords (you can have somebody do that while you are doing the DL keeping soft tissue out of the way)

2) you already have a bougie available, so you just slip it down until it hits the kink... pull the tube back until the kink disappears - advance the bougie down that trachea and then advance over it

3) inflate the cuff a bit - that changes the dynamics of the tube and it makes it harder to kink over

4) if you have a GRADE I view - and the pt desats without being able to advance the tube, I would leave the nasal rae in the pharynx... . give a hit of mivacurium or low dose sux (15-25mg) and more hypnotic agent... then place an oral ETT... give a few breaths to bring sats back up and go to steps 1 through 3...

 

[toofache32]

I've worked with attendings who insist on having a nasal rae in the oven. I think this works against you for this exact reason. I've never seen it play out this dramatic before, but this is the reason I never liked those limp tubes. It's like trying to do other things with limp "equipment." And I rarely get any nasal bleeding (cocaine) or inability to pass the tube through the nares (KY) even though I don't warm my nasal raes.

 

[CanGas]

Now that is why I like this forum. Periodic nurse bashing and constant "The Match" threads aside, I actually learn stuff. I have not found any anesthesia forums to match it anywhere else (hey, if you know of any more let me know). Not just "book learning" information but "holy crap that's a great idea" kind of practical stuff that can only be obtained by experience on your own or shared by someone with greater experience.

Thanks Tenesma, I had thought about the FOB but no, we did not have it in the room. Staffman thought we would be ok. Some of your other stratigies could have made our life easier though when it hit the fan. We did ok in the end but certainly not elegant and not something I would choose to repeat.