jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
Heres a case we did last night...

49 y/o ASA 1 36 hrs S/P facelift and bilat bleph. Getta call from the plastic surgeon (10pm), the lady has an expanding facial hematoma. Needs to evacuate hemotoma...said it'll take about 45 min.

In the ER, lady looks like she got hit by a two-by-four. Left entire cheek/jaw area is grossly swollen. No dyspnea, no stridor. Tracheal deviation to the right about an inch. Ate a few tablespoons of applesauce at 5pm.

How do you proceed?
 

zippy2u

Senior Member
10+ Year Member
5+ Year Member
Feb 19, 2005
501
5
Status
awake nasal fiberoptic intubation with GA--- why burn bridges? -----Zip
 

MAC10

A Pimp Named Slickback
10+ Year Member
5+ Year Member
Dec 28, 2004
156
0
Status
jetproppilot said:
Heres a case we did last night...

49 y/o ASA 1 36 hrs S/P facelift and bilat bleph. Getta call from the plastic surgeon (10pm), the lady has an expanding facial hematoma. Needs to evacuate hemotoma...said it'll take about 45 min.

In the ER, lady looks like she got hit by a two-by-four. Left entire cheek/jaw area is grossly swollen. No dyspnea, no stridor. Tracheal deviation to the right about an inch. Ate a few tablespoons of applesauce at 5pm.

How do you proceed?
What did her airway look like? Can she even open her mouth? Also did any swelling/hematoma extend to the submandibular area? With lots of facial swelling I would be wondering if I could even get a good mask on this lady when she goes down and what i would encounter with the laryngoscope esp with her tracheal deviation. I would go with an awake nasal fiberoptic as well. Also, she ate 5 hours ago, a small amount and a while ago but still. We treat everything from the ER as a full stomach. I would get pepcid in her asap, reglan and bicitra to follow. May consider sucking stomach intraop and antiemetics.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
Visit site
Status
Attending Physician
inject the skin above the worst part of the hematoma with some lidocaine, make a skin incision and thread in a penrose drain to decompress the hematoma.... then re-address/re-evaluate airway.... then proceed w/ what is appropriate...

oh... ask the surgeon first if he wants to make that little skin nick :) and then adamantly deny that you ever gave her toradol during the initial case :D
 

Noyac

10+ Year Member
Jun 20, 2005
7,893
2,563
Status
Attending Physician
All good choices. I like the idea of evacuating the hematoma with very little sedation but enough to keep her calm and her BP down so as not to increase the bleeding. I would start by sedating her with precedex. Next, I would do a trans-tracheal injection in preparation for a awake FOB intubation. When I perform the trans-tracheal, I would inject through a 16 or 18 gauge jellco cath and leave it in place in case the airway is lost so I could jet ventilate. As soon as the hematoma is evacuated I would proceed with FOB (oral or nasal). I would not let the plastics guy do anything more than evacuate until I had a definitive airway. The more he mucks around the more edema he will cause and then you will be using that jellco. After the ETT is in place he can finish the case.
I did a bring back carotid this way one evening because of a hematoma that was deviating the trachea about as much as Jet described. Except that once the hematoma was evacuated I let the Vascular Dude find the bleeder because the pt was sedated well and doing fine. As soon as the case was over (approx'ly 20 min) I was talking to the guy and right in front of my face he obstructed completely, turned blue and the only thing I could do was grab a MAC 4 and go in. The soft tissue was so edematous the I couldn't hardly see a thing. Then from nowhere came a bubble and I went for it. It was luckily the trachea and all was fine. I don't want to do that again.
 
OP
jetproppilot

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
jetproppilot said:
Heres a case we did last night...

49 y/o ASA 1 36 hrs S/P facelift and bilat bleph. Getta call from the plastic surgeon (10pm), the lady has an expanding facial hematoma. Needs to evacuate hemotoma...said it'll take about 45 min.

In the ER, lady looks like she got hit by a two-by-four. Left entire cheek/jaw area is grossly swollen. No dyspnea, no stridor. Tracheal deviation to the right about an inch. Ate a few tablespoons of applesauce at 5pm.

How do you proceed?
I'll tell you how we did it tomorrow.

Anybody else?
 

Monitor

Membership Revoked
Removed
10+ Year Member
Oct 7, 2005
70
0
Status
Medical Student
Trach the bitch while she's awake, that'll teach her to get plastic surgery :eek: :wow:
 
OP
jetproppilot

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
MAC10 said:
What did her airway look like? Can she even open her mouth? Also did any swelling/hematoma extend to the submandibular area? With lots of facial swelling I would be wondering if I could even get a good mask on this lady when she goes down and what i would encounter with the laryngoscope esp with her tracheal deviation. I would go with an awake nasal fiberoptic as well. Also, she ate 5 hours ago, a small amount and a while ago but still. We treat everything from the ER as a full stomach. I would get pepcid in her asap, reglan and bicitra to follow. May consider sucking stomach intraop and antiemetics.
Submandibular area was moderately swollen, hence the tracheal deviation to the right.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
18
Visit site
Status
Attending Physician
Hard for me to say without a picture of the patient. But the safe thing would be some sort of spontaneous ventilating intubation.
 

davvid2700

Membership Revoked
Removed
10+ Year Member
Jul 31, 2005
348
0
42
Status
jetproppilot said:
Heres a case we did last night...

49 y/o ASA 1 36 hrs S/P facelift and bilat bleph. Getta call from the plastic surgeon (10pm), the lady has an expanding facial hematoma. Needs to evacuate hemotoma...said it'll take about 45 min.

In the ER, lady looks like she got hit by a two-by-four. Left entire cheek/jaw area is grossly swollen. No dyspnea, no stridor. Tracheal deviation to the right about an inch. Ate a few tablespoons of applesauce at 5pm.

How do you proceed?

awake fiberoptic.. period... if none available.. spray her down.. judicious use of ketamine.. (to maintain spontaneous ventilation).. use a miller 2 to take a look.. but the best is awake fiberoptic there is absolutely no reason why you shouldnt do that. oral fiberoptic..

The oral surgeon brings cases like this to us frequently..
 
OP
jetproppilot

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
jetproppilot said:
Heres a case we did last night...

49 y/o ASA 1 36 hrs S/P facelift and bilat bleph. Getta call from the plastic surgeon (10pm), the lady has an expanding facial hematoma. Needs to evacuate hemotoma...said it'll take about 45 min.

In the ER, lady looks like she got hit by a two-by-four. Left entire cheek/jaw area is grossly swollen. No dyspnea, no stridor. Tracheal deviation to the right about an inch. Ate a few tablespoons of applesauce at 5pm.

How do you proceed?
Alright. Heres my thoughts. And heres how we did it.

For all med students & residents, there is no "right" answer here. Actually our answer was "right" in that it worked and we arrived in the PACU without incident. Military has made reference to that. Get the pt to the PACU safely, and you were "right". But there will be differing opinions on how to handle the case. All are "right", as long as they work.

Just like landing an airplane. Get the bird on the tarmac, reverse thrust, exit to the taxi-way. Whatever you did to make that happen, it was "right".

I'm gonna go against the grain here. I didnt think awake fiberoptic was a viable option.

Read Noyac's post. He had a carotid who sailed through the scary part of the case, but occluded when he least expected it. What if the airway occlusion occurs while you are prepping/performing the awake fiberoptic? To the posters, have you ever done an awake fiberoptic on an expanding neck/face hematoma for whatever reason (S/P CEA, etc)?

An awake fiberoptic intubation takes pretty controlled conditions, in my humble opinion. Doing an awake fiberoptic is easy when you give glycopyrrolate preop, have plenty of time to prep...which takes some time...anesthetize the nasopharynx with lidocaine jelly and a nasal airway, laryngeal blocks, transtracheal blocks, chloroprocaine spray to the oropharynx...

OR, the alternative (which is superior in my humble opinion), screw all the blocks. If you sedate the pt with Precedex, you really dont need all the blocks essential for an awake intubation. Noyac described this.

But Precedex sedation takes about ten minutes to efficacy, then add on the time to do the fiberoptic.

How many clinicians out there have REALLY done an awake fiberoptic on an EMERGENCY case where the airway is distorted? And, where time is of the essence, are you really gonna take the time to prep the airway when, as Noyac pointed out, you cant predict when you will lose the airway?

Yes, awake fiberoptic intubation is a great response to a board examiner. But I challenge you to take the time to prep the airway for an awake intubation with an expanding hematoma. I'm thinking trach all the way.....and preparing for that...and in the mean time, I'll take a less invasive route. But if it fails, plan B is already in place.

This lady was in the OR 15 minutes after she hit the ER, with a 22" IV placed in her AC by the ER Trauma Nurses. :thumbdown:

I was ready, but not by the awake fiberoptic route.

She rolls into the OR, on the table, and I was ready to jet ventilate her. Had already marked her cricothyroid membrane, knew where to stick the angio, (way right of midline), had the jet ventilator already set up. I've done that before, and was ready to do it again. I felt more confident doing that than trying to drive a fiberoptic scope through a distorted airway...and I consider myself pretty deft with the scope. But again, I'm thinking time is of the essence.

Remember that preoxygenation in an ASA 1 pt buys you ALOT of time. Probably 3 minutes to desaturation. So we preoxygenated her well.

Propofol 120mg. Apnea. Able to ventilate well. Sevoflurane cranked to the max. Hyperventilated. Still no problems ventilating.

Miller 2, looking wide right, cords, tube, ETCO2. Very distorted airway, but able to get the tube in.

Total time?? Cuppla minutes.

Surgeon evacuates all the clot, checks for bleeders, close.

Total time, 45 minutes.
 

davvid2700

Membership Revoked
Removed
10+ Year Member
Jul 31, 2005
348
0
42
Status
oohh.... ouch...... ouch...


The gods were looking after you...


was she stridorous when she "hit" the OR...


given this info.. I would have done an awake look.. I would not have taken away her spontaneous respirations if i could help it .. Unless you are ready and willing to provide a subglottic airway " cric or ttjv" which you were..

This is what i think i would do..
tell her what you're doin'
spray with 4 percent lido.. 2 seconds of benzocaine.( to avoid methemoglobinemia) miller 2.. hope for the best.. but she is still breathing.. if she completely obrstructs.. go to ttjv or cric....
If i see cords. then i would feel better with proceeding with a rapid sequence .....

alternatively, fiberoptic scope.. If she wasnt stridorous ,I have time. IF its bloody.. I can still do the FO. just connect the o2 to the port to blow the secretions away.. and plug away until you see cords.. If she obstructs while you are doing the FO>. go to TTJV or cric.. after you try to mask ventilate and it proves to be fruitless..

tough airway issues.. doesnt take much to back you into a corner..
 

Disse

Member
10+ Year Member
7+ Year Member
Dec 20, 2004
110
0
Status
Attending Physician
Interesting case and always nice to see how others proceed.

I think important issues regarding FOB are availability of equipment and exactly how quickly the hematoma is expanding. As long as an FOB is easily accessible and you have folks other than you in the OR that you trust (i.e. can actually give you a hand if you need it in someway--jaw thrust etc.) I don't think it takes too long long to prep for an FOB.

1) Glyco as soon as you see them.
2) Start topicalization, supplementary O2 and sedation
3) Precedex would be a fantastic choice (if you're comfortable with the stuff you can bolus it for quicker onset...)

This doesn't take more than a few minutes either.

Alternatively, get the patient comfortable and breath her down with Sevo.

Importantly with hematomas, IMHO, is that you try to maintain a very calm environment. Two examples of this:

A) Patient s/p anterior cervical disc the day before, ate some pancakes for breakfast, neurosurgeons sees in the morning shortly thereafter and patient has an expanding neck hematoma, mild stridor.

Emergent to OR. Plan for awake FOB. Start topicalization/sedation/antisialogue but (looking back in hindsight) probably was a bit rushed (bad bad bad) and this patient was one of the "Oh Jesus.. Oh Lordy" types. Start the FOB, patient gets a little frantic, BP goes up and neck hematoma starts getting really big really fast. Tell surgeon to get ready to trach, convert to RSI and luckily get the tube in. (Patient makes it to PACU safely post-evac with the only real downside being the 10 years off of my life)

B) Patient s/p thyroidectomy with expanding neck hematoma. Ate a sandwich an hour before. Surgeon very resistant to decompression under local prior to intubation (patient was an MD friend of his). FOB available. Good topicalization, good antisialogue and good sedation (just versed/fentanyl) all started in PACU and continued in OR. No transtracheal. Pt seated. FOB advanced, cords seen/sprayed with lido. Scope through cords, propofol/ETT advanced simultaneously. Pt. makes it to the PACU in good shape, pats on the shoulder from surgeon ( :eek: ) and I didn't lose any more years to spend with my kids (that day).


I think another key point that has been emphazised (but I'll do so too) is ALWAYS ALWAYS PREPARE AS IF THE AIRWAY WILL BE LOST. Know where the cricothyroid membrane is, have ttjv equipment available, tell the surgeon they need to be prepared to trach, blah blah blah blah...and get as much supplemental O2 as you can to the patient.

Nice case
 

DenRock

Oxygen Addict
10+ Year Member
5+ Year Member
Feb 10, 2005
21
0
Pittsburgh, PA
Status
Attending Physician
My thoughts on this one:

Even the direct laryngoscopy on a heavily sedated (asleep) patient seems somewhat reasonable with a good backup plan. I think this might be a case where retrograde wire intubation would be a good plan. Sometimes with severe tracheal deviation there can also be glottic rotation, where the glottic opening is pointing other than toward the laryngoscopist. This would make even the passage of a FOB difficult or impossible. As is the case with both retrograde wire and FOB intubation - these do not guarantee the passage of an endotracheal tube is possible. There can always be hang-ups at the glottic opening. Therefore, I would only proceed if I had someone present who could pull off an emergency trach, i.e. general surgery.
 

Noyac

10+ Year Member
Jun 20, 2005
7,893
2,563
Status
Attending Physician
For those of you that have used precedex for sedation by bolusing would you describe your technique. To this date I have had enough time to start the infusion as I was topicalizing the airway. I Have an idea as to how to do it, loading dose, etc. But some direction would help.

Nice case Jet. This is the reason this site keeps me coming back. My only other comment about this case for those of you in training is, get good with the FOB. If you are not comfortable then this type of case will be a disaster. The longer you take to scope them the bigger that hematoma becomes and eventually you won't see ****. Then its trach time. And that plastic surgery pt has now got a scar on her pretty little throat assuming that you or the surgeon can get into the trachea with it deviated. If that hematoma crosses in front of the trachea, its gonna be a bloody mess and all bets are off. If that hematoma is on the right side of the face it will likely be more difficult. In my last year of training I would grab the scope for the day. I would induce my pt tell the OR team to continue with the prep and I would FOB orally. After a short while I had it down, usually within 30 secs. or less. Just some thoughts.
 
OP
jetproppilot

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
davvid2700 said:
awake fiberoptic.. period... if none available.. spray her down.. judicious use of ketamine.. (to maintain spontaneous ventilation).. use a miller 2 to take a look.. but the best is awake fiberoptic there is absolutely no reason why you shouldnt do that. oral fiberoptic..

The oral surgeon brings cases like this to us frequently..
Sounds like you need to find another oral surgeon to work with. :scared:
 

Disse

Member
10+ Year Member
7+ Year Member
Dec 20, 2004
110
0
Status
Attending Physician
Noyac said:
For those of you that have used precedex for sedation by bolusing would you describe your technique. To this date I have had enough time to start the infusion as I was topicalizing the airway. I Have an idea as to how to do it, loading dose, etc. But some direction would help.

Nice case Jet. This is the reason this site keeps me coming back. My only other comment about this case for those of you in training is, get good with the FOB. If you are not comfortable then this type of case will be a disaster. The longer you take to scope them the bigger that hematoma becomes and eventually you won't see ****. Then its trach time. And that plastic surgery pt has now got a scar on her pretty little throat assuming that you or the surgeon can get into the trachea with it deviated. If that hematoma crosses in front of the trachea, its gonna be a bloody mess and all bets are off. If that hematoma is on the right side of the face it will likely be more difficult. In my last year of training I would grab the scope for the day. I would induce my pt tell the OR team to continue with the prep and I would FOB orally. After a short while I had it down, usually within 30 secs. or less. Just some thoughts.

If you dont have a pump you can simply inject 1 ug/kg of precedex in a 100cc bag of saline and just run it in (within reason). Alternatively you can give 20-40 ug boluses IV q3-5 minutes (which really won't save you any time though over a 10 min load).

Do have to watch for hypertension & bradycardia though with quicker bolusing.
 

augmel

Senior Member
10+ Year Member
15+ Year Member
Oct 7, 2002
275
1
Visit site
Status
Sorry to veer towards ICU from airway emphasis, but since anesthesia does ICU care too, I think it is relevent. When I was in the ICU, we would babysit the post-op neurosurg, ent patients who had neck operations. My resident (and I think the surgeons, can't remember) told me that if a patient s/p neck op begins to have respiratory distress, that I should just go ahead and cut the sutures, open up the wound to drain, and then call the surgeon. This is a community ICU without surgeons or anesthesia in house overnight, just us residents. The thought of doing this scared the crap out of me. Does this sound crazy or reasonable, given that it would take at least 15-20 minutes to have gas and surgery there? Maybe this is hard to imagine if you have only ever been in a university hospital.
 

Noyac

10+ Year Member
Jun 20, 2005
7,893
2,563
Status
Attending Physician
augmel said:
Sorry to veer towards ICU from airway emphasis, but since anesthesia does ICU care too, I think it is relevent. When I was in the ICU, we would babysit the post-op neurosurg, ent patients who had neck operations. My resident (and I think the surgeons, can't remember) told me that if a patient s/p neck op begins to have respiratory distress, that I should just go ahead and cut the sutures, open up the wound to drain, and then call the surgeon. This is a community ICU without surgeons or anesthesia in house overnight, just us residents. The thought of doing this scared the crap out of me. Does this sound crazy or reasonable, given that it would take at least 15-20 minutes to have gas and surgery there? Maybe this is hard to imagine if you have only ever been in a university hospital.
Sounds reasonable to me but you better be sure that there is a problem when you do it because the surgeons I know would have your ass if you did this unnecessarily. This is what I was talking about in my first post. If you drain it first you will have more room to work with and less tracheal deviation.
 

Noyac

10+ Year Member
Jun 20, 2005
7,893
2,563
Status
Attending Physician
Something else to think about in this case is when to extubate and how? This will be just as important as the intubation.
 

Poety

10+ Year Member
5+ Year Member
Dec 22, 2004
2,227
1
46
Bible Belt and loving it
Status
Resident [Any Field]
Noyac said:
Something else to think about in this case is when to extubate and how? This will be just as important as the intubation.

I'm going into psych, just want to say, after reading these threads I have such a new respect for anesthesiology, not that I didn't before but whoa -I don't even know what half those things are you guys were talking about.

I did however fall in love with my anesthesiologist during labor hehe :) he was GOOD, REALLLL good ;) <Thanking the almighty epi Gods>
 

MAC10

A Pimp Named Slickback
10+ Year Member
5+ Year Member
Dec 28, 2004
156
0
Status
When you guys are guys are doing FOB after induction, do you have to patient breating spontaneously? What do you use to induce?
 

thegasman

ASA Member
10+ Year Member
15+ Year Member
Sep 29, 2003
354
0
southeast
Visit site
Status
Attending Physician
MAC10 said:
When you guys are guys are doing FOB after induction, do you have to patient breating spontaneously? What do you use to induce?

If you are doing this for difficult airway then definitely ketamine (premed with robinul helps keep down the increased secretions with this), it keeps them breathing. If it is a "normal" airway and you are just playing around with the scope for practice then use standard induction. Do just what you would normally do. Propofol and sux or ndnmb and then fob ( or any other appropriate induction combo.)
 

toofache32

15+ Year Member
Apr 19, 2003
3,873
36
Status
Resident [Any Field]
jetproppilot said:
Sounds like you need to find another oral surgeon to work with. :scared:
I was wondering about that also. Are these elective cases or infections where the airway is distorted?