Consensus on a previous difficult airway

[2Fast2Des]

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I'd like to give some narcan

Oral board guy: patient is now in florid pulmonary edema, next step

 

[DM27]

I am a fan of Midazolam for awakes. As a matter of context, I otherwise dislike Midazolam and rarely ever use it. My reasoning for its use in awakes is it can help mellow people out a bit and as a convenient byproduct a lot of people don't believe me afterwards when I remind them they were awake for the intubation. My maybe clinically relevant, likely doesn't matter, but still a decent justification reasoning for its use is that it can favorably alter the seizure threshold for the amount of lidocaine I am about to dump in.

 

[Arch Guillotti]

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.

Volatile would be the absolutely last thing I would do if performing an AFOI.

There is absolutely nothing wrong with titrating fentanyl - predictable sedation that is easily titrated, can be reversed and also can help with cough reflex.

 

[vector2]

Volatile would be the absolutely last thing I would do if performing an AFOI.

There is absolutely nothing wrong with titrating fentanyl - predictable sedation that is easily titrated, can be reversed and also can help with cough reflex.

As I said, I'm talking about the orals, not the real world. IRL many of us use fent or remi for AFOI and it's fine 99.99% of the time, however the examiners aren't interested in the fine option, they're interested in knowing whether you know the safest option (which is stone cold awake with topicalization followed prn with meds that don't cause respiratory depression).

IRL, I'm also not that big a fan of vapor for spontaneously breathing intubation, but vapor is a tried and true answer for securing the airway in tamponade, mediastinal mass, etc

 

[Arch Guillotti]

IRL, I'm also not that big a fan of vapor for spontaneously breathing intubation, but vapor is a tried and true answer for securing the airway in tamponade, mediastinal mass, etc

Neither of which the patient has😵

 

[Twiggidy]

Oral board guy: patient is now in florid pulmonary edema, next step

Trach

 

[Psai]

Oral board guy: patient is now in florid pulmonary edema, next step

Tube, ppv, lasix, foley, next

 

[XRanger]

Our pulmonologists do bronch under conscious sedation all the time here with nurses giving versed/fentanyl. That’s like an AFOI.

My go to technique for suspected difficult airway is to do mask induction, do a quick look with glide, if I can see the cord easily then sux and intubate

 

[vector2]

Neither of which the patient has😵

Im not quite sure how many times I have to say I'm talking about oral board generalities before you get it..

 

[deleted697535]

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.

Supine afoi? Do you like pain? That sounds horrendous lol
I guess different strokes eh

 

[deleted697535]

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.

Agree and disagree.
If you said I'd give a 'bit ' of anything you're in soup for sure.
But if you say you'd give titrated sedation with whatever to RAS 0, or sedate with an infusion of whatever with the appropriate infusion rates ready if they ask, all while spont vent with rr monitored then you're golden.
If they obstruct a bit then ask nurse for jaw thrust/stimulate, halt infusion that should be fine too...
It's fairly common. Doesn't mean you have to abandon and go straight to front of neck or anything

If an exam expects you do do a fully awake afoi without any sedation then screw that. It's a bad exam. Completely not in keeping with the real world. I don't think that examiners think that way... I hope they don't anyway. If they do they should be sacked. And probably haven't given an anesthetic themselves in years

 

[anbuitachi]

Supine afoi? Do you like pain? That sounds horrendous lol
I guess different strokes eh

we do 99% of our AFOI supine. only sitting if they can't lie down without dying

Agree and disagree.
If you said I'd give a 'bit ' of anything you're in soup for sure.
But if you say you'd give titrated sedation with whatever to RAS 0, or sedate with an infusion of whatever with the appropriate infusion rates ready if they ask, all while spont vent with rr monitored then you're golden.
If they obstruct a bit then ask nurse for jaw thrust/stimulate, halt infusion that should be fine too...
It's fairly common. Doesn't mean you have to abandon and go straight to front of neck or anything

If an exam expects you do do a fully awake afoi without any sedation then screw that. It's a bad exam. Completely not in keeping with the real world. I don't think that examiners think that way... I hope they don't anyway. If they do they should be sacked. And probably haven't given an anesthetic themselves in years

its not like written exams are a good representation of real world experience. i wont be surprised if some oral examiners are like that too

 

[Arch Guillotti]

we do 99% of our AFOI supine. only sitting if they can't lie down without dying

🙁😕😱

 

[Mman]

we do 99% of our AFOI supine. only sitting if they can't lie down without dying

I do them almost all sitting up because I can stand in front of them off to the side and it maximizes the chances of keeping their tongue from falling into the back of their pharynx which is my biggest enemy on a nasal FOI.

 

[anbuitachi]

Anyone do them lateral?

 

[deleted162650]

Anyone do them lateral?

No, always prone. Keeps the tongue outta the way.

 

[Psai]

Supine afoi? Do you like pain? That sounds horrendous lol
I guess different strokes eh

I do a lot of things that I don't necessarily think are ideal

 

[sevoflurane]

I do a lot of things that I don't necessarily think are ideal

39 fr. DLT being placed in the lateral position.... yup... that wasn't ideal although it needed to be done at the time... when seconds count....

 

[narcotics999]

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.

Why did you need to do this case at midnight? Airway obstruction?

 

[sevoflurane]

Why did you need to do this case at midnight? Airway obstruction?

Festering abscess on top of his cancer.

 

[jwk]

No, always prone. Keeps the tongue outta the way.

Ah - same thing happens doing a prone mask case 🙂