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.
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.
