Consensus on a previous difficult airway

[turnupthevapor]

Tomorrows gastric sleeve has a history of a difficult airway and was looking for a consensus on the approach.......moderate size pt maybe 350, airway looks maybe a touch tight not crazy hard, good mouth opening, maybe a M3-4, nl TM. Looks maskable.

In 2015 she said she was a tough airway. I got the record. Anesthesiologist tried 5 times with a glidescope and than his colleague came in and got it. No real notes about specifics just that the lowest the SAT was 74%.

I called the anesthesiologist but he said he didn't remember the case.

how would all you jedi types approach this airway tomorrow AM?

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[Arch Guillotti]

Glidescope, positioning, long preoxygenation, bougie, fiberoptic, LMA you can intubate through. Prop, sux, tube.

 

[MoMoGesiologist]

It's three years later. This patient has probably only gotten bigger and airway more difficult. You may be lucky and be the guy who gets the glidescope intubation on the first try. Or you may be the guy who fails the first five attempts and the patient desats to 74% do you call for help.

Patient has already warned you she is a tough airway. What else would you need before you decide on awake intubation? Why risk it? If you induce and can't get the airway and your partners ask for the history, do you feel comfortable defending your decision making? For those reasons I would probably AFOI even though there's a reasonable chance you could simply induce and DL or glide intubate. If the patient didn't come in with that history, I think it would make sense to induce as normal. She's just so large that she'll desat very quickly no matter how much you pre-oxygenate.

 

[anbuitachi]

Tomorrows gastric sleeve has a history of a difficult airway and was looking for a consensus on the approach.......moderate size pt maybe 350, airway looks maybe a touch tight not crazy hard, good mouth opening, maybe a M3-4, nl TM. Looks maskable.

In 2015 she said she was a tough airway. I got the record. Anesthesiologist tried 5 times with a glidescope and than his colleague came in and got it. No real notes about specifics just that the lowest the SAT was 74%.

I called the anesthesiologist but he said he didn't remember the case.

how would all you jedi types approach this airway tomorrow AM?

The record didn't say how hard ventilation was? or what view they were able to get? no mention of why it was hard?

 

[vector2]

Tomorrows gastric sleeve has a history of a difficult airway and was looking for a consensus on the approach.......moderate size pt maybe 350, airway looks maybe a touch tight not crazy hard, good mouth opening, maybe a M3-4, nl TM. Looks maskable.

In 2015 she said she was a tough airway. I got the record. Anesthesiologist tried 5 times with a glidescope and than his colleague came in and got it. No real notes about specifics just that the lowest the SAT was 74%.

I called the anesthesiologist but he said he didn't remember the case.

how would all you jedi types approach this airway tomorrow AM?

Were they an easy mask on the previous record? If so just repeat glidescope with a fiber and intubating LMA available. If not, do it awake.

I gotta say, in the age of EMR, not taking 5 minutes to write a brief intubation note describing exactly what you saw and did after you instrumented 5 times is some of the laziest BS on earth. These whales are inevitably going to come back for GI, vascular, or ortho surgery; you do yourself and the pt a big disservice by not putting in clear documentation at the time of the initial event.

 

[nimbus]

We don’t get many opportunities to AFOI these days. I would do it with that history even knowing she had a successful GS intubation in the past.

 

[deleted162650]

Since you have the luxury of knowing who the original anesthesiologist was, ask yourself:

Is he a Jedi Master or a donkey?

If a donkey, then prop/sux/GS/tube.

If a Jedi, AFOI.

 

[deleted697535]

We don’t get many opportunities to AFOI these days. I would do it with that history even knowing she had a successful GS intubation in the past.

Amen. And i used to scoff at North American AFOI heavy usage.

Now my eyes are open (and i learned some skills) it take no longer than the time it takes to pump the roc around.
Ive been doing 2 or 3 a week this last while (just been doing a lot of ENT). It takes 3-5 mins and is good fun, very safe, and very good for your skills base. And your reputation as a bad a$$ skilled mofo will grow. At the end of the day, our one and only job is airway.

100% shes getting AFOI. Why wouldnt you? Its no big deal. How is it different to say using a glidescope with the tube on the fibrescope as a smart bougie?

When you get good at judging sedation/topicalisation patients dont even remember it.

 

[deleted697535]

Tomorrows gastric sleeve has a history of a difficult airway and was looking for a consensus on the approach.......moderate size pt maybe 350, airway looks maybe a touch tight not crazy hard, good mouth opening, maybe a M3-4, nl TM. Looks maskable.

In 2015 she said she was a tough airway. I got the record. Anesthesiologist tried 5 times with a glidescope and than his colleague came in and got it. No real notes about specifics just that the lowest the SAT was 74%.

I called the anesthesiologist but he said he didn't remember the case.

how would all you jedi types approach this airway tomorrow AM?

How many AFOI you done recently? And whats your plan?

 

[deleted171991]

Tomorrows gastric sleeve has a history of a difficult airway and was looking for a consensus on the approach.......moderate size pt maybe 350, airway looks maybe a touch tight not crazy hard, good mouth opening, maybe a M3-4, nl TM. Looks maskable.

In 2015 she said she was a tough airway. I got the record. Anesthesiologist tried 5 times with a glidescope and than his colleague came in and got it. No real notes about specifics just that the lowest the SAT was 74%.

I called the anesthesiologist but he said he didn't remember the case.

how would all you jedi types approach this airway tomorrow AM?

Awake glidescope look after glycopyrrolate and lidocaine topicalization in preop area. Takes me 5 minutes. Peace of mind... priceless!

If good view, preoxygenate and induce in the same position in the OR. If bad view, awake fiberoptic with some precedex (or your favorite poison).

Btw, I exercise my upper airway topicalization skills on every single EGD I do. To quote one of my recent patients (whom I had to keep light because of the aspiration risk): "I had an idea what was going on, but I didn't care because I was not feeling anything".

 

[deleted697535]

Awake glidescope look after glycopyrrolate and lidocaine topicalization in preop area. Takes me 5 minutes. Peace of mind... priceless!

If good view, preoxygenate and induce in the same position in the OR. If bad view, awake fiberoptic with some precedex (or your favorite poison).

I think thats not a great plan, im sorry FFP!
Glidescope might give you a fine view but angling the tube in is a different story! And what if you cant bag her?
In the 5 mins you take to topicalise and do awake glide (which i believe will tell you nothing more than you already know) (and potentially risk losing her faith in you), AFOI will have the tube in and you'll be sitting down to find the billing codes


There are probably at least 5 ways to do this, and i suppose it all depends on your skills. And there will never be a consensus! lol

 

[deleted171991]

I think thats not a great plan, im sorry FFP!
Glidescope might give you a fine view but angling the tube in is a different story! And what if you cant bag her?
In the 5 mins you take to topicalise and do awake glide (which i believe will tell you nothing more than you already know) (and potentially risk losing her faith in you), AFOI will have the tube in and you'll be sitting down to find the billing codes


There are probably at least 5 ways to do this, and i suppose it all depends on your skills. And there will never be a consensus! lol

Angling the tube? Use a #4 glidescope blade in all patients (regardless of size) and you will rarely (if ever) have problems passing the tube (you will have much more space than with a #3).

Even assuming that's the case, if you have a good view, you can pass a bougie and slide the tube down on it.

In the morbidly obese, one should not waste time trying to ventilate. If one is not SURE one can RSI the patient (or easily ventilate, based on recent experience), one should not put her to sleep.

Why would the patient loose faith in me? Au contraire, I tend to gain their trust once they put the glidescope down their own throat.

 

[deleted162650]

"I had an idea what was going on, but I didn't care because I was not feeling anything".

You can try and convince us that a patient told you that, but we all know it was your wife.

 

[Urzuz]

Probably the most important thing I have learned after the years I've been in solo practice is this - if you ever even THINK of doing something that is slightly more work in the name of safety/concern, DO IT (e.g.: you think about intubating vs just LMA -- INTUBATE. You think of placing arterial line / additional IV - PLACE THEM).

In this case, just do the AFOI and sleep easy tonight instead of soiling yourself.

 

[ZzzPlz]

If this isn’t a case for retrograde wire I don’t know what is

 

[facted]

To me it comes down to if she was easy to ventilate: Yes --> Asleep, either fiberoptic or GS. No --> Awake FOI.D

 

[Psai]

Ramp it up with like six blankets. Afoi.

 

[deleted697535]

Angling the tube? Use a #4 glidescope blade in all patients (regardless of size) and you will rarely (if ever) have problems passing the tube (you will have much more space than with a #3).

A bored certified anesthesiologist failed massively on this airway with your exact plan and you plan on doing the exact same but you expect a different result...

You're probably right too. I guess most every non cancer, non syndromic non trauma patient is intubate able via glidescope.
But...

I just wonder why you'd take that risk for no gain. If you're wrong youre fairly wide open. If you're right you've already spent 5 mins extra outside the or doing your plan.

 

[Arch Guillotti]

Awake glidescope look after glycopyrrolate and lidocaine topicalization in preop area. Takes me 5 minutes. Peace of mind... priceless!

If good view, preoxygenate and induce in the same position in the OR. If bad view, awake fiberoptic with some precedex (or your favorite poison).

Bad idea. If you have a good view squirt with lidocaine and then intubate.

 

[deleted171991]

Bad idea. If you have a good view squirt with lidocaine and then intubate.

That's the safest, for sure. My awake look is not that deep, so it's much less unpleasant than an awake intubation. In the right hands, one doesn't need much topicalization for an awake intubation with precedex, ketamine or remi. My favorite memory is with droperidol and almost no topicalization during residency.

There is more than one way to skin the cat.

 

[anbuitachi]

Amen. And i used to scoff at North American AFOI heavy usage.

Now my eyes are open (and i learned some skills) it take no longer than the time it takes to pump the roc around.
Ive been doing 2 or 3 a week this last while (just been doing a lot of ENT). It takes 3-5 mins and is good fun, very safe, and very good for your skills base. And your reputation as a bad a$$ skilled mofo will grow. At the end of the day, our one and only job is airway.

100% shes getting AFOI. Why wouldnt you? Its no big deal. How is it different to say using a glidescope with the tube on the fibrescope as a smart bougie?

When you get good at judging sedation/topicalisation patients dont even remember it.

2-3 awakes a week? that's a lot of awakes per week..

 

[MoMoGesiologist]

Amen. And i used to scoff at North American AFOI heavy usage.

Now my eyes are open (and i learned some skills) it take no longer than the time it takes to pump the roc around.
Ive been doing 2 or 3 a week this last while (just been doing a lot of ENT). It takes 3-5 mins and is good fun, very safe, and very good for your skills base. And your reputation as a bad a$$ skilled mofo will grow. At the end of the day, our one and only job is airway.

100% shes getting AFOI. Why wouldnt you? Its no big deal. How is it different to say using a glidescope with the tube on the fibrescope as a smart bougie?

When you get good at judging sedation/topicalisation patients dont even remember it.

3min AFOI?? What's your technique??

 

[anbuitachi]

3min AFOI?? What's your technique??

sux the patient awake and put the tube in with fiberoptic. Still counts as AFOI if awake but paralyzed right

 

[deleted162650]

2-3 awakes a week? that's a lot of awakes per week..

3min AFOI?? What's your technique??

Ya, who does this guy think he is - Blade???

 

[Psai]

sux the patient awake and put the tube in with fiberoptic. Still counts as AFOI if awake but paralyzed right

Give the pt some versed at least goddam

 

[deleted59964]

I would do this with AFOI, but if I was going to prop, roc, tube - preoxygenation would include THRIVE

 

[DM27]

With that history and even that level of detail I would just do an awake fiberoptic. If you've done enough to be comfortable it should take <10 minutes overall. The easiest way I've found to save time is to use IV glyco followed by nebulized 4% Lidocaine in the holding area to get >50% of the topicalization done there. At that point I generally finish up with an atomizer in OR to get a deeper topicalization and then proceed. If you have access to an epidural catheter that fits down your fiberoptic channel you can also do SAYGO. I sometimes do this to spray the cords, but I've found a true SAYGO approach to be somewhat time consuming and amounts to a bit too much time with the fiberoptic in someone's mouth.

If you don't have the luxury of holding area topicalization then a pure atomizer technique ultimately amounts to still <10 minutes.

 

[deleted697535]

Ya, who does this guy think he is - Blade???

Just been doing ENT every day including oncall for emergencies. It's actually been 6 in 10 days now

It's not my technqiue. It's the most common remi protocol that's been published. I do add some twists but they don't add time.

Neb lido, glyco, 1 or 2 midaz, start remi at .2 mcg/kg/min until .6 or .7 mcg/kg have have been given. So that's 3 to 4 mins.
While waiting spray lido up the nose and I make a little viscous paste of 2% lido too that I try get them to gargle. At 3 mins they're usually ready. Just give them a shove and if theyre slow to open their eyes you're ready.
The bronch itself takes 10 seconds. I use a 6 oral tube on everyone between 30kg and 50kg. A 6.5 nasal on everyone over 50kg. Adult scope on everyone. All patients sit bolt upright. Screen behind their head. I stand in front. Iv on their left hand. Intubate the left nostril. Head turned towards me. Nurse to hold their hand. And instructed to give a jaw thrust if I need it. Also nurse has 2 cc of 4% lido in a syringe to squirt down the side port of the scope

The adult scope will take a 6 oral tube but it's tight. It doesn't seem to take a 6 nasal. It's too tight. But length of tube on these small people isn't a problem.

There are subtlies to this that I am figureing out all the time.

I don't even use an infusion really any more of remi. Just 10 to 15 mcg bolus every min until the same dose.

If they're obstructing with a tumor be very careful. This is not a technique for that. Drastically reduce doses and wait much longer. If they're just difficult airway but fully oxygenated this is a good technique.

I've used dexmed, fent/midaz etc. But I think I like remi best

 

[Twiggidy]

Maybe I just have big hands.

Most people even the big’ns are able to be mask ventilated, especially women who likely doesn’t have a beard (im assuming).

Evaluate. Asleep. Whatever video technique you prefer. The person who actually needs to be kept awake to secure the airway is quite rare.

 

[Twiggidy]

sux the patient awake and put the tube in with fiberoptic. Still counts as AFOI if awake but paralyzed right

 

[BeatriZZ]

Awake glidescope look after glycopyrrolate and lidocaine topicalization in preop area. Takes me 5 minutes. Peace of mind... priceless!

If good view, preoxygenate and induce in the same position in the OR. If bad view, awake fiberoptic with some precedex (or your favorite poison).

Btw, I exercise my upper airway topicalization skills on every single EGD I do. To quote one of my recent patients (whom I had to keep light because of the aspiration risk): "I had an idea what was going on, but I didn't care because I was not feeling anything".

Somewhat off topic but how do you figure you exercise upper airway topicalization skills on every EGD do you. Please elaborate.
Surely you don't do transtracheal blocks, lidocaine nubulizers, and SLN blocks for an EGD!
Also, if your patient is at such a high risk for aspiration, wouldn't keeping them light and knocking out their cough reflex make them more likely to aspirate?

 

[turnupthevapor]

Thank you all for your input, i read each of your posts and appreciate the thoughts tremendously.

So the patient came in this AM and although she was 360 lb she was damn near a M1 (maybe a 2) with a nl chin TM dist, nl neck ROM, and certainly no signs of inability to ventilate. My plan was optimal positioning (head strap, ramp, sniff, PreO2 in RT) than prop-sux-glide. Back up plan was the FOB was in the room and hooked up to do a glide assisted bougie type technique if needed or a fast trach FOB combo.

So we put the glide 3 blade in and BAMMO.......................... it was a C-L GRADE ONE view with no difficulty. I guess the previous clinician WITH THEIR FIVE ATTEMPTS either had poor positioning or was inept (or just having a bad day). Case went well (20 minute sleeve) and we all live happily ever after.

Thank you again

 

[btbam]

Thank you all for your input, i read each of your posts and appreciate the thoughts tremendously.

So the patient came in this AM and although she was 360 lb she was damn near a M1 (maybe a 2) with a nl chin TM dist, nl neck ROM, and certainly no signs of inability to ventilate. My plan was optimal positioning (head strap, ramp, sniff, PreO2 in RT) than prop-sux-glide. Back up plan was the FOB was in the room and hooked up to do a glide assisted bougie type technique if needed or a fast trach FOB combo.

So we put the glide 3 blade in and BAMMO.......................... it was a C-L GRADE ONE view with no difficulty. I guess the previous clinician WITH THEIR FIVE ATTEMPTS either had poor positioning or was inept (or just having a bad day). Case went well (20 minute sleeve) and we all live happily ever after.

Thank you again

20 min? Holy fook.

 

[Psai]

Thank you all for your input, i read each of your posts and appreciate the thoughts tremendously.

So the patient came in this AM and although she was 360 lb she was damn near a M1 (maybe a 2) with a nl chin TM dist, nl neck ROM, and certainly no signs of inability to ventilate. My plan was optimal positioning (head strap, ramp, sniff, PreO2 in RT) than prop-sux-glide. Back up plan was the FOB was in the room and hooked up to do a glide assisted bougie type technique if needed or a fast trach FOB combo.

So we put the glide 3 blade in and BAMMO.......................... it was a C-L GRADE ONE view with no difficulty. I guess the previous clinician WITH THEIR FIVE ATTEMPTS either had poor positioning or was inept (or just having a bad day). Case went well (20 minute sleeve) and we all live happily ever after.

Thank you again

It's not just the patient though, sometimes the situation can turn an easy airway into a disaster.

 

[Mman]

3min AFOI?? What's your technique??

I get like 75% of the work done in preop holding before we even roll back to the OR. Give them some glyco to dry up secretions, a little afrin in the nose, and then some lidocaine gel smeared on a nasal airway and let that sit for maybe 3-5 minutes in their nose. Then take that airway out and upsize to a little bigger eventually getting up to a 32 or 34 Fr nasal airway. Then roll them back to the OR with a little versed or dexmeditomidine on board and spray some lidocaine through the nasal trumpet via a LMA Madgic atomizer while they inhale to coat the back of their pharynx and their cords. At that point just slide out the nasal trumpet and slide in the nasal ETT and take a peak through the fiberoptic scope. The tube is generally sitting already lined up with their vocal cords and you just advance in and call it a day and then push some propofol. The actual in the OR part really doesn't take more than a few minutes at most depending on how slow and gentle you are trying to be with getting the tube in their already numb nose. Nasal tubes practically place themselves in the trachea.

 

[Psai]

I get like 75% of the work done in preop holding before we even roll back to the OR. Give them some glyco to dry up secretions, a little afrin in the nose, and then some lidocaine gel smeared on a nasal airway and let that sit for maybe 3-5 minutes in their nose. Then take that airway out and upsize to a little bigger eventually getting up to a 32 or 34 Fr nasal airway. Then roll them back to the OR with a little versed or dexmeditomidine on board and spray some lidocaine through the nasal trumpet via a LMA Madgic atomizer while they inhale to coat the back of their pharynx and their cords. At that point just slide out the nasal trumpet and slide in the nasal ETT and take a peak through the fiberoptic scope. The tube is generally sitting already lined up with their vocal cords and you just advance in and call it a day and then push some propofol. The actual in the OR part really doesn't take more than a few minutes at most depending on how slow and gentle you are trying to be with getting the tube in their already numb nose. Nasal tubes practically place themselves in the trachea.

This is like when the surgeon says they will only take 30 mins but you're actually in the or for another hour and half

 

[deleted162650]

Thank you all for your input, i read each of your posts and appreciate the thoughts tremendously.

So the patient came in this AM and although she was 360 lb she was damn near a M1 (maybe a 2) with a nl chin TM dist, nl neck ROM, and certainly no signs of inability to ventilate. My plan was optimal positioning (head strap, ramp, sniff, PreO2 in RT) than prop-sux-glide. Back up plan was the FOB was in the room and hooked up to do a glide assisted bougie type technique if needed or a fast trach FOB combo.

So we put the glide 3 blade in and BAMMO.......................... it was a C-L GRADE ONE view with no difficulty. I guess the previous clinician WITH THEIR FIVE ATTEMPTS either had poor positioning or was inept (or just having a bad day). Case went well (20 minute sleeve) and we all live happily ever after.

Thank you again

Sooooo, not a Jedi Master?

 

[Twiggidy]

Thank you all for your input, i read each of your posts and appreciate the thoughts tremendously.

So the patient came in this AM and although she was 360 lb she was damn near a M1 (maybe a 2) with a nl chin TM dist, nl neck ROM, and certainly no signs of inability to ventilate. My plan was optimal positioning (head strap, ramp, sniff, PreO2 in RT) than prop-sux-glide. Back up plan was the FOB was in the room and hooked up to do a glide assisted bougie type technique if needed or a fast trach FOB combo.

So we put the glide 3 blade in and BAMMO.......................... it was a C-L GRADE ONE view with no difficulty. I guess the previous clinician WITH THEIR FIVE ATTEMPTS either had poor positioning or was inept (or just having a bad day). Case went well (20 minute sleeve) and we all live happily ever after.

Thank you again

See. 50% of the time it works every time.

 

[sevoflurane]

Had one of my toughest airways this year. Bad, bad, neck-oral-pharynegal cancer super duper crap your pants badness. Mouth opening was a few millimeters. Literally no possibility of glidescope or AFO through the mouth. Only way in was nasal or trach.
Of course... this was at midnight on a Tuesday.
Was able to get my Nasal FO, but should have just trached him from the get go.
Dude had minimal work up and ended up on my lap in the middle of the night. Did the case, but transferred him to Stanford where he received a face half-ectomy and then died 3 months later from his disease. AW cases can be ball busters and come in unexpectedly sometimes.

 

[GassmanMD]

Spray airway with local anesthetic of choice. Small touch of propofol, then let the patient breath sevo until they are unconscious but breathing spontaneously. Take a look with glidescope. If you see a grade 1 view, sux then tube. If not, you have all the time in the world to adjust because the patient is still breathing. Do this a lot and it works.

 

[anbuitachi]

Had one of my toughest airways this year. Bad, bad, neck-oral-pharynegal cancer super duper crap your pants badness. Mouth opening was a few millimeters. Literally no possibility of glidescope or AFO through the mouth. Only way in was nasal or trach.
Of course... this was at midnight on a Tuesday.
Was able to get my Nasal FO, but should have just trached him from the get go.
Dude had minimal work up and ended up on my lap in the middle of the night. Did the case, but transferred him to Stanford where he received a face half-ectomy and then died 3 months later from his disease. AW cases can be ball busters and come in unexpectedly sometimes.

How did patient eat? sounds like you can't even fit a straw thru that mouth opening

 

[deleted697535]

Spray airway with local anesthetic of choice. Small touch of propofol, then let the patient breath sevo until they are unconscious but breathing spontaneously. Take a look with glidescope. If you see a grade 1 view, sux then tube. If not, you have all the time in the world to adjust because the patient is still breathing. Do this a lot and it works.

So you plan on Gassing someone who you have already identified might obstruct? What if they do go on ahead and obstruct while being light? What do you do then?

Sorry but I don't think this is a good idea at all. It works and I used to do it admittedly. But it's still a bad idea and I'm glad I've abandoned it. There are far better options

 

[Mman]

This is like when the surgeon says they will only take 30 mins but you're actually in the or for another hour and half

except the tube is in within 5 minutes of rolling into the OR and that includes hooking up monitors. It just takes more time out in preop holding between cases. But I've got all the time in the world for that as the AA or CRNA can finish rolling the previous patient to PACU and turning over the room. I mean it literally takes less OR time to do the awake intubation than it does to do standard preoxygenation and IV induction and masking and intubating, it's just a little less pleasant for the patient and takes more of my time in preop holding. But those 5-10 minutes in preop holding of dilating their nose really isn't that long.

 

[pgg]

Had one of my toughest airways this year. Bad, bad, neck-oral-pharynegal cancer super duper crap your pants badness. Mouth opening was a few millimeters. Literally no possibility of glidescope or AFO through the mouth. Only way in was nasal or trach.
Of course... this was at midnight on a Tuesday.
Was able to get my Nasal FO, but should have just trached him from the get go.
Dude had minimal work up and ended up on my lap in the middle of the night. Did the case, but transferred him to Stanford where he received a face half-ectomy and then died 3 months later from his disease. AW cases can be ball busters and come in unexpectedly sometimes.

Had a case like that a few years back. Called by the ER in the middle of the night to tube a person with a tongue base cancer who'd previously refused a trach.

It didn't help that they were giving her racemic epi to treat her "stridor" which gave her a heart rate of 130something and some ST depression.

I stopped the epi, took one ill-advised look with a fiber, saw a big broccoli shaped mass begging to bleed if I touched it, bailed out, told her she needed a trach, and called ENT for an awake trach. Should not have let the ER talk me into trying.

 

[vector2]

This thread is a good example of how the real world differs from the boards. For the padawans lurking here who are studying for orals, just keep in mind that in an AFOI situation (which inevitably will be on the exam) if you say 'I'd give a bit of prop or fentanyl' the next words out of the examiner's mouth will be 'pt is now obstructing/desatting/apneic, how would you like to proceed?'

If your plan for a stem is AFOI then stick to a truly awake plan. If they push you (pt is freaking out, pt is a kid), start with reassurance and additional excellent topicalization, and only then proceed to medications that minimally suppress respiratory drive I.e. Dex, ketamine, volatile.

 

[Noyac]

Just do AFOI.

 

[drmwvr]

Ramp it up with like six blankets. Afoi.

Ramp? That implies a supine intubation by DL. One of the benefits of an AFOI is that the patient is sitting comfortably upright. Is that what you meant?

 

[drmwvr]

If your plan for a stem is AFOI then stick to a truly awake plan. If they push you (pt is freaking out, pt is a kid), start with reassurance and additional excellent topicalization, and only then proceed to medications that minimally suppress respiratory drive I.e. Dex, ketamine, volatile.

Step one in a slickly successful AFOI is to sell it to the patient for 100% buy in. The rest is style points...

 

[Psai]

Ramp? That implies a supine intubation by DL. One of the benefits of an AFOI is that the patient is sitting comfortably upright. Is that what you meant?

Ive done them both supine and sitting. But I figured it would be good to have them in position if you needed to try something else.

 

[Mman]

I'd give a bit of prop or fentanyl' the next words out of the examiner's mouth will be 'pt is now obstructing/desatting/apneic, how would you like to proceed?'

I'd like to give some narcan