difficult airway in the ED

[sifidawkins]

Pt (5'6" 70 kg) presents to ED confused but talking with Sats in high 80's and possible aspiration pneumonitis on CXR. ER doc decides to intubate, but can't after several attempts with Mac 4, Miller 4 or glidescope. Pt received etomidate and sux. What should happen next?

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[sifidawkins]

Of note I posted a similar thread in the EM forum and was asked why posted in EM instead of gas where my other posts were. Therefore I want to see the difference in responses here vs. there.

 

[countingdays]

Pt (5'6" 70 kg) presents to ED confused but talking with Sats in high 80's and possible aspiration pneumonitis on CXR. ER doc decides to intubate, but can't after several attempts with Mac 4, Miller 4 or glidescope. Pt received etomidate and sux. What should happen next?

Have the ER take to OG blade out of the goose and have an Anesthesiologist DL with Miller 2. Until then I'm not convinced that this is a difficult airway, apart from the trauma from multiple attempts, unless there is more to the story that I haven't seen.

 

[Fastrach]

Pt (5'6" 70 kg) presents to ED confused but talking with Sats in high 80's and possible aspiration pneumonitis on CXR. ER doc decides to intubate, but can't after several attempts with Mac 4, Miller 4 or glidescope. Pt received etomidate and sux. What should happen next?

Well, if you want to follow the standard of care and go by the difficult airway algorithm, the answer is an LMA. Don't know what's such a big mystery. I'm guessing they went with a glidescope next? No no, probably the lightwand...

 

[sifidawkins]

Have the ER take to OG blade out of the goose and have an Anesthesiologist DL with Miller 2. Until then I'm not convinced that this is a difficult airway, apart from the trauma from multiple attempts, unless there is more to the story that I haven't seen.

You are making a big assumption...that there was an anesthesiologist present...they were not called at this point. YOu are right that this should not be a difficult airway, but at this time for the ED staff it is. (Before this case I did not realize that a Miller 4 exists)

 

[sevoflurane]

Pt (5'6" 70 kg) presents to ED confused but talking with Sats in high 80's and possible aspiration pneumonitis on CXR. ER doc decides to intubate, but can't after several attempts with Mac 4, Miller 4 or glidescope. Pt received etomidate and sux. What should happen next?

ABC's. Establish an AW with mask ventilation and OA. Get sats up. Check the rest of the vitals and make them better. Hand over AW to anesthesiologist let him take a look and decide the next course of action. Continued attempts can cause obnoxious edema/bloody AW's. If you can't mask ventilate and sats are in the toilet... Trach time... you can temporize with LMA but prepare for surgical AW.

Often people are more worried about a protected AW and forget about how good and effective mask ventilation can be... especially 2 handed. Not always the case though.

 

[sevoflurane]

BTW... 5'6'' and 70kgs... should be an easy mask ventilation even in the face of a difficult AW. That's a BMI of 25.

 

[Arch Guillotti]

Closing. This topic is essentially cross-posted in the ED forum and anyone wanting to contribute can join in that thread.