Difficult Airway

[sifidawkins]

I'm curious what different institutions do in the case of difficult airways. This comes from a recent incident at my institution in which there was a difficult airway which resulted in a less than favorable outcome. What steps are taken if a patient who is being semi-electively intubated (was confused but talking with Sats in high 80's and possible aspiration pneumonitis on CXR prior to intubation attempt) is a difficult intubation and can't be tubed with standard blade or glidescope? Pt received etomidate and sux.

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[kungfufishing]

This depends on what is available, what you like, and your assessment of their airway prior to your attempt. My own algorithm for RSI is DL or glidescope--> LMA or ILMA ---> bougie cric. I assume this was not a predicted difficult airway?

 

[2bnevryorfis]

To quote Ron Walls....."The difficult airway is anticipated, the failed airway is experienced."
-Without knowing more about the case its difficult to answer what could have been done.
-i.e., was the patient difficult to bag (beard, edentulous, etc), difficult to place an EGD (mallampati, obesitiy)?
-When all else fails and you end in an can't intubate/can't oxygenate scenario = cricothyrotomy

That being said, at our shop we have multiple devices to handle the difficult airway (Mac blades, Miller, Glidescope, Karl Storz CMAC, Bougie, LMA, Intubating LMA, King Airway, Flexible Fiberoptic, Rigid Fiberoptic, Cric Kits) We have two difficult airway carts that are stocked identical so you always know where and what is available.

 

[Hamhock]

Flexible Fiberoptic

Really? Wow. I have yet to come across an EM doc (without previous training or cross-training) who has enough experience to even try a flex fiberoptic. Are your residents really trained to do this? If so - awesome. What program are you at, if you don't mind exposing yourslef? (or, if you do, would you PM me to satisfy my curosity)

Am I that out of it? Are other folks using flex fiberoptics in the ED?

HH

 

[yahoomail]

Really? Wow. I have yet to come across an EM doc (without previous training or cross-training) who has enough experience to even try a flex fiberoptic. Are your residents really trained to do this? If so - awesome. What program are you at, if you don't mind exposing yourslef? (or, if you do, would you PM me to satisfy my curosity)

Am I that out of it? Are other folks using flex fiberoptics in the ED?

HH

Fibreoptic intubations are not uncommon by any means at my institution as well. Especially if I anticipate it is going to be a difficult intubation, I have it ready by the bedside, just in case. If I know that it is a difficult intubation (i.e. angioedema etc.), I will use it as my first tool.

 

[Hamhock]

Fibreoptic intubations are not uncommon by any means at my institution as well. Especially if I anticipate it is going to be a difficult intubation, I have it ready by the bedside, just in case. If I know that it is a difficult intubation (i.e. angioedema etc.), I will use it as my first tool.

do you mean use of a fiberoptic stylet (eg Levitan)? or do you really mean a flexible fiberoptic scope (eg fiberoptic bronchoscope)?

if you mean option #2 - cool!...if you mean option #1, well I don't count that as a "flex fiberoptic", as 2bnevryorfis mentioned in the prior post

HH

 

[yahoomail]

do you mean use of a fiberoptic stylet (eg levitan)? Or do you really mean a flexible fiberoptic scope (eg fiberoptic bronchoscope)?

If you mean option #2 - cool!...if you mean option #1, well i don't count that as a "flex fiberoptic", as 2bnevryorfis mentioned in the prior post

hh

#2

 

[Arcan57]

Really? Wow. I have yet to come across an EM doc (without previous training or cross-training) who has enough experience to even try a flex fiberoptic. Are your residents really trained to do this? If so - awesome. What program are you at, if you don't mind exposing yourslef? (or, if you do, would you PM me to satisfy my curosity)

Am I that out of it? Are other folks using flex fiberoptics in the ED?

HH

Really? You've never seen a nasal fiberoptic intubation in the ED? It's not a cure-all (secretions mess with your view horribly, and it's rare we have time to pre-treat with glycopyrrolate or atropine). But in the angioedema pt you're using an NP scope to check the posterior pharynx anyway, why not have a tube loaded so if needed you intubate on that pass?

Sifidawkins, is there any reason you're posting this on the EM forum rather than the gas forum where you've posted previously?

 

[sifidawkins]

Really? You've never seen a nasal fiberoptic intubation in the ED? It's not a cure-all (secretions mess with your view horribly, and it's rare we have time to pre-treat with glycopyrrolate or atropine). But in the angioedema pt you're using an NP scope to check the posterior pharynx anyway, why not have a tube loaded so if needed you intubate on that pass?

Sifidawkins, is there any reason you're posting this on the EM forum rather than the gas forum where you've posted previously?

Absolutely there is a reason why it is posted in the EM forum rather than the gas forum where I've posted previously! First off the problem occurred in the ED and they went from can't intubate straight to an open cricothyroidotomy. So I was wondering if that was the teaching in the emergency room. If you present this same scenario to any competent anesthesiologist they will inevitably point to the difficult airway algorithm!!! I was curious to see if EM trained physicians would refer to it or if they even know that it exists. Some of the responses here have hit on steps of the algorithm and others seem to be missing critically important ones. Just remember that it's failing to ventilate that causes problems, not failing to intubate.

 

[Arcan57]

Difficult airway and failed airway algorithms are part of every EM training program.

Now run along back under your bridge...

 

[MushieCookie]

Absolutely there is a reason why it is posted in the EM forum rather than the gas forum where I've posted previously! First off the problem occurred in the ED and they went from can't intubate straight to an open cricothyroidotomy. So I was wondering if that was the teaching in the emergency room. If you present this same scenario to any competent anesthesiologist they will inevitably point to the difficult airway algorithm!!! I was curious to see if EM trained physicians would refer to it or if they even know that it exists. Some of the responses here have hit on steps of the algorithm and others seem to be missing critically important ones. Just remember that it's failing to ventilate that causes problems, not failing to intubate.

Really...are you seriously asking this?

 

[IlDestriero]

Difficult airway and failed airway algorithms are part of every EM training program.

Now run along back under your bridge...

I'm not sure why you would call this person a troll, the difficult or failed airway algorithms are not black and white A, B, C -> 1, 2, 3. Plenty of room for discussion.
I would make sure the patient was optimally positioned, go back to attempt bag mask ventilation with an OPA and 1 or 2 Nasal airways, call for the difficult airway cart, extra hands, and prep the neck.

 

[Arcan57]

The OP could easily have a discussion with the physicians who staff their emergency department regarding what their protocol was for difficult/failed airways. If the OP was interested in a discussion of the protocols from a technical standpoint, it seems that the gas forum would host a plethora of experts. If the OP is looking for validation in their airway management superiority, the gas forum has a number of "look what the dumb EP did to the airway" threads. Since the OP chose this forum to question whether EM physicians have any training in difficult airways and chose to use semi-inflammatory language (as well as multiple unnecessary exclamation points), I'm calling troll.

 

[pgg]

You're coming off awfully trollish, sifidawkins.

You play games crossposting an incomplete scenario and it's unclear if you're really curious "what different institutions do" or if you're really here to lecture the EM guys what "competent anesthesiologists" do.

 

[sifidawkins]

The one aspect that I was looking for to create more discussion which has not been mentioned would be waking the pt up! In this case I feel that it is reasonable, especially if mask ventilation or ventilation with an LMA is established first. I'll admit my initial intent probably was not pure but it was not pure "trolling". I did want to hear various thoughts on a case with interesting learning points.

 

[Tiger26]

The one aspect that I was looking for to create more discussion which has not been mentioned would be waking the pt up! In this case I feel that it is reasonable, especially if mask ventilation or ventilation with an LMA is established first. I'll admit my initial intent probably was not pure but it was not pure "trolling". I did want to hear various thoughts on a case with interesting learning points.

since this seems to be your catch, you also have to keep in mind that you initially wrote the pt had sats in the 80s (and i presume respiratory distress) and was to the point of confusion.

now the question is why is the pt confused? although it's probably secondary to hypoxia, it could run the gamut from baseline dementia to head bleed, stroke, sepsis, EtOH, toxic ingestion, electrolyte abnormality, metabolic disturbance (thyrotoxicosis, hyperosmolar hyperglycemia, DKA), cholangititis, UTI . . . . .

Either way, this pt is obviously a sick guy/gal. While it's easy to just wake up a pt in the OR under controlled circumstances and previous medical clearance for surgery, we deal in immediate life threats. This pt needs an ET tube someway/somehow and there clearly isn't time at that point for a discussion of the pluses/minus of every possible option.

At our place, it would be continuous NRB, optimal pt ramping with blankets behind shoulder blades, pushing drugs while sitting up, then DL-->bougie or glidescope-->cric

One thing to mention as well is that oral airways can be lifesavers in pts with a high degree of soft tissue who are difficult to bag

 

[Arcan57]

The one aspect that I was looking for to create more discussion which has not been mentioned would be waking the pt up! In this case I feel that it is reasonable, especially if mask ventilation or ventilation with an LMA is established first. I'll admit my initial intent probably was not pure but it was not pure "trolling". I did want to hear various thoughts on a case with interesting learning points.

The level of detail supplied in your initial post would have been an excellent jumping of point for a lecture on difficult airways aimed at the med student/intern level. The level was woefully insufficient as an attempt to generate a focused discussion on an Internet forum. The reason for the inability to intubate, why the cric lead to an adverse outcome, letting paralysis wear off if intubation failed, etc. would all be more likely to generate a useful/informative discussion.

In terms of letting paralysis wear off, that is a technique that is far more useful when a patient is not in respiratory failure prior to intubation. What do I expect to be different in the patient's status once the paralysis wears off?

 

[Coastie]

I'm curious what different institutions do in the case of difficult airways. This comes from a recent incident at my institution in which there was a difficult airway which resulted in a less than favorable outcome. What steps are taken if a patient who is being semi-electively intubated (was confused but talking with Sats in high 80's and possible aspiration pneumonitis on CXR prior to intubation attempt) is a difficult intubation and can't be tubed with standard blade or glidescope? Pt received etomidate and sux.

Call the anesthesiologist.

In the meantime, ventilate with BMV or LMA.

What happens when you place the blade or glide? What do you see? What's making this difficult?

 

[pinipig523]

If you think the airway is tough - do awake intubation. Urojet, viscous lido, reglan, AND lido nebs + glycopyrolate/atropine.

However, if not - just anticipate who has crap in their stomach. Don't overbag, preoxygenate early, reglan. DL -> Glidescope -> Bougie.

 

[Arch Guillotti]

The one aspect that I was looking for to create more discussion which has not been mentioned would be waking the pt up! In this case I feel that it is reasonable, especially if mask ventilation or ventilation with an LMA is established first. I'll admit my initial intent probably was not pure but it was not pure "trolling". I did want to hear various thoughts on a case with interesting learning points.

Waking a patient up who started out with sats in the 80's?

Good luck.

 

[Arch Guillotti]

Either way, this pt is obviously a sick guy/gal. While it's easy to just wake up a pt in the OR under controlled circumstances and previous medical clearance for surgery, we deal in immediate life threats. This pt needs an ET tube someway/somehow and there clearly isn't time at that point for a discussion of the pluses/minus of every possible option.

At our place, it would be continuous NRB, optimal pt ramping with blankets behind shoulder blades, pushing drugs while sitting up, then DL-->bougie or glidescope-->cric

Waking a patient up in the OR is not always so cut and dry. True "can't intubate, can't ventilate" scenarios are extremely rare but when you are in one sometimes you have to act so fast or the patient is so sick that you don't have the luxury of simply waking them up.

I find it kind of crazy that you go straight to cric if you are unable to intubate via traditional means. There are many other alternatives in this situation so long as you can ventilate.

 

[Arch Guillotti]

If you think the airway is tough - do awake intubation. Urojet, viscous lido, reglan, AND lido nebs + glycopyrolate/atropine.

However, if not - just anticipate who has crap in their stomach. Don't overbag, preoxygenate early, reglan. DL -> Glidescope -> Bougie.

What's a urojet?

I am not an EM doc but I would imagine that not many patients are in a position where you have the luxury of an awake intubation - and I am curious to know how many EM docs are trained in awake intubations and how many actually do them.

I am curious how you anticipate who has crap in their stomach. I would assume they are all full stomach unless they are able to give a good history otherwise.

I understand the rationale for Reglan but I think it is doubtful that it really does any good.

All patients should be preoxygenated early and not overbagged, especially in an urgent/emergent situation.

Relying on the glidescope as the end-all be-all is a mistake in my opinion since sometimes it fails.

 

[Rendar5]

urojet is 2% viscous lidocaine that comes packaged in a little squirt tube. it's called such because the container is designed to squirt it into a urethra prior to catheterization, thus the name.

 

[Arcan57]

What's a urojet?

I am not an EM doc but I would imagine that not many patients are in a position where you have the luxury of an awake intubation - and I am curious to know how many EM docs are trained in awake intubations and how many actually do them.

I am curious how you anticipate who has crap in their stomach. I would assume they are all full stomach unless they are able to give a good history otherwise.

I understand the rationale for Reglan but I think it is doubtful that it really does any good.

All patients should be preoxygenated early and not overbagged, especially in an urgent/emergent situation.

Relying on the glidescope as the end-all be-all is a mistake in my opinion since sometimes it fails.

I've trained and done awake nasal fiberoptic intubations. Have seen awake DL intubations done, but given the time it took to get everything set-up
anaesthesia would have been available.

 

[docB]

I find it kind of crazy that you go straight to cric if you are unable to intubate via traditional means. There are many other alternatives in this situation so long as you can ventilate.

No one in EM is ever taught that can't intubate means go to cric. No one. If they say they are they either misunderstood or were grievously led astray in their training.

The actual approach is that if you can't intubate and can't ventilate then you go to a surgical airway. Can't intubate and can't ventilate is much more rare than the typical difficult airway.

In the can't intubate situation the EP will use BLS airway techniques to ventilate and then use other modalities as appropriate to the situation, ie. different blades, bougie, video laryngoscopy, LMA/Fastrach, Combitube/King etc., scopes, needle cric w/wo retrograde intubation and so on.

I am not an EM doc but I would imagine that not many patients are in a position where you have the luxury of an awake intubation - and I am curious to know how many EM docs are trained in awake intubations and how many actually do them.

Everyone is trained in doing awake tubes but their use has really fallen off since the widespread advent of RSI. They used to be done a lot in the old days pre RSI particularly in COPDers. The reason was that once you gave a patient enough old style, pre-RSI sedative like Versed to get them tubed you had suppressed their respiratory drive. Since they were by definition in respiratory failure to begin with that interval would often drop their sats from 80% to bradycardic. Since you were usually intubating a poorly sedated patient in a high pressure situation the use of brutane and therefore airway trauma went up. For those reasons awake intubations used to be done a lot more often than they are now. There are even a number of adjuncts for use with these such as the BAAM and the nasotracheal auscultation device, which, like the procedure, have fallen into disfavor.

I am curious how you anticipate who has crap in their stomach. I would assume they are all full stomach unless they are able to give a good history otherwise.

I always assume everyone has a full stomach. This is why RSI has come into such widespread use in EM.

 

[Tiger26]

Waking a patient up in the OR is not always so cut and dry. True "can't intubate, can't ventilate" scenarios are extremely rare but when you are in one sometimes you have to act so fast or the patient is so sick that you don't have the luxury of simply waking them up.

I find it kind of crazy that you go straight to cric if you are unable to intubate via traditional means. There are many other alternatives in this situation so long as you can ventilate.

sorry--meant to add the caveat of cric if unable to ventilate after trying other means. FWIW, I'm a big fan of oral airways, which nearly always solve that problem, esp in more soft-tissue endowed pts, which I noted later in my post

 

[Arch Guillotti]

No one in EM is ever taught that can't intubate means go to cric. No one. If they say they are they either misunderstood or were grievously led astray in their training.

The actual approach is that if you can't intubate and can't ventilate then you go to a surgical airway. Can't intubate and can't ventilate is much more rare than the typical difficult airway.

In the can't intubate situation the EP will use BLS airway techniques to ventilate and then use other modalities as appropriate to the situation, ie. different blades, bougie, video laryngoscopy, LMA/Fastrach, Combitube/King etc., scopes, needle cric w/wo retrograde intubation and so on.

I think I was responding to this:

At our place, it would be continuous NRB, optimal pt ramping with blankets behind shoulder blades, pushing drugs while sitting up, then DL-->bougie or glidescope-->cric

which seemed to imply a very quick conversion to cric although the OP did qualify things a bit right afterwards with a blurb about oral airways.

I am well aware of the difficult airway algorithm and have been down the path up close and personal more than once.

As I have said before, the ED guys I am used to are pretty good at managing the airway and although I think that there are fundamental differences in the way we are trained the nuances of the differences aren't that big of a deal as long as you can manage the airway effectively.

 

[Arch Guillotti]

Everyone is trained in doing awake tubes but their use has really fallen off since the widespread advent of RSI. They used to be done a lot in the old days pre RSI particularly in COPDers. The reason was that once you gave a patient enough old style, pre-RSI sedative like Versed to get them tubed you had suppressed their respiratory drive. Since they were by definition in respiratory failure to begin with that interval would often drop their sats from 80% to bradycardic. Since you were usually intubating a poorly sedated patient in a high pressure situation the use of brutane and therefore airway trauma went up. For those reasons awake intubations used to be done a lot more often than they are now. There are even a number of adjuncts for use with these such as the BAAM and the nasotracheal auscultation device, which, like the procedure, have fallen into disfavor.

Sounds elegant.

The whole goal of an awake intubation for an anesthesiologist is add odds with your description of old-school ED awake intubation above - our goal is maintaining spontaneous ventilation, not abolishing it. Also we will almost always block the required cranial nerves.

Is the nasotracheal auscultation device the little whistle thinghy?

Awake nasals seem to be rarely performed these days but it can be a lifesaver at the right time.

 

[Dwindlin]

Sounds elegant.

The whole goal of an awake intubation for an anesthesiologist is add odds with your description of old-school ED awake intubation above - our goal is maintaining spontaneous ventilation, not abolishing it. Also we will almost always block the required cranial nerves.

Is the nasotracheal auscultation device the little whistle thinghy?

Awake nasals seem to be rarely performed these days but it can be a lifesaver at the right time.

The whistle thingy is a BAAM, and yeah it's what is used to assist placing a nasotracheal tube. One of the EMS services I worked for that didn't have RSI used nasotracheal tubes in patients with a gag reflex who were in resp. failure, was also useful in non-facial trauma with trismus assuming still had some spontaneous resp.

 

[pgg]

Relying on the glidescope as the end-all be-all is a mistake in my opinion since sometimes it fails.

I've had more than one person, in and out of anesthesia, tell me that they feel the Glidescope has been a game changer. It seems a lot of people feel that it's become reasonable to just induce & paralyze difficult-looking airways because the Glidescope is there to save the day.

Less than a month ago I got called stat for a desaturating patient in the OR because the CRNA on call with me had just RSI'd an obese ZZ-Top-bearded noneck patient. Backup plan: Glidescope.

She couldn't get a view with it. I fiddled with it for a few seconds and got a grade 4-ish glimpse, but couldn't pass either a tube or bougie through. Glidescope out, OP & NP airways in, had a great deal of trouble ventilating but got sats back up. I got the tube in with a fiberoptic scope.

 

[Coastie]

Good point. People also forget the learning curve with the glidescope...it isn't just look and place...

Why weren't you in the OR when the CRNA you were on call with RSI'd a zz-top patient?

I've had more than one person, in and out of anesthesia, tell me that they feel the Glidescope has been a game changer. It seems a lot of people feel that it's become reasonable to just induce & paralyze difficult-looking airways because the Glidescope is there to save the day.

Less than a month ago I got called stat for a desaturating patient in the OR because the CRNA on call with me had just RSI'd an obese ZZ-Top-bearded noneck patient. Backup plan: Glidescope.

She couldn't get a view with it. I fiddled with it for a few seconds and got a grade 4-ish glimpse, but couldn't pass either a tube or bougie through. Glidescope out, OP & NP airways in, had a great deal of trouble ventilating but got sats back up. I got the tube in with a fiberoptic scope.

 

[Arch Guillotti]

Agree 100%. The glidescope is great but I am not convinced it is a deal breaker and I don't think anyone should rely on it as a rock-solid rescue device. We could sit here all day and bore the EM folks with tales of hairy airways but from my perspective the take home message as an anesthesiologist is that it is a faulty assumption to think that the glidescope is going to bail you out of every bad situation.

I've had more than one person, in and out of anesthesia, tell me that they feel the Glidescope has been a game changer. It seems a lot of people feel that it's become reasonable to just induce & paralyze difficult-looking airways because the Glidescope is there to save the day.

Less than a month ago I got called stat for a desaturating patient in the OR because the CRNA on call with me had just RSI'd an obese ZZ-Top-bearded noneck patient. Backup plan: Glidescope.

She couldn't get a view with it. I fiddled with it for a few seconds and got a grade 4-ish glimpse, but couldn't pass either a tube or bougie through. Glidescope out, OP & NP airways in, had a great deal of trouble ventilating but got sats back up. I got the tube in with a fiberoptic scope.

 

[dchristismi]

I tend to agree. I've had a couple of anticipated difficult airways that I started with the glidescope and couldn't see anything. Whipped out the trusty MAC-4 and easily slipped it in. It certainly isn't the end-all-be-all, but it's a nice adjunct.

I'm glad to see that this discussion is staying constructive.
And for the record, I'm an EM attending who isn't comfortable with the fiberoptic scope. I have lots of other adjuncts, but that ain't one of them.

 

[iridesingltrack]

Agree 100%. The glidescope is great but I am not convinced it is a deal breaker and I don't think anyone should rely on it as a rock-solid rescue device. We could sit here all day and bore the EM folks with tales of hairy airways but from my perspective the take home message as an anesthesiologist is that it is a faulty assumption to think that the glidescope is going to bail you out of every bad situation.

Agree. Like any other airway tool we use we must have proficiency born out of practice. In addition no device is 100 percent effective that is why it is just one of the devices and adjuncts we can employ.

 

[kungfufishing]

tangentially related, have any of you used the glidescope for kids? It intuitively seems like it might be particularly useful in this setting. We have the pees sized blades but have yet to use it. Dchristismi provided a glimpse of my own experience with the glidescope as well - I have had airways I anticipated difficult made easier/smoother/gentler using the glidescope. I've also started with the camera and quickly decided to finish with the metal.

 

[pgg]

Why weren't you in the OR when the CRNA you were on call with RSI'd a zz-top patient?

This is an opt out state. They don't need my help, until they do.

 

[CambieMD]

I prefer the Bullard over the Glidescope.The Bullard is better suited for patients with small mouths and limited neck extension. I have had difficulty passing the ETT with the Glidescope. I can maneuver the Bullard better during critical situations with the airway.

The intubating LMA should not be overlooked also. You can reestablish ventilation and intubate the patient in two steps.

Obviously, for angioedema awake nasal is the safest noninvasive method of establishing an airway.

Cambie

 

[proman]

The most successful instrument for a difficult airway is the one you are most proficient in. For me, if DL by conventional means (metal blade of 1 flavor x1, the other flavor x1), I would next use the Glidescope. If that is unavailable or unsuccesful, I place a regular LMA and use a fiberoptic/Aintree combination. That's what I've done multiple times and it has yet to fail me. I hope to retire before it does.

 

[lushmd]

In continuing with the glidescope tangent, there's an article in the lastest issue of Anesthesiology regarding this very issue (use of the glidescope in patients in whom conventional laryngoscopy was either anticipated or proven to be difficult).

EDIT: Also, there's another article by the same PI looking at emergent non-operative intubations. Interestingly, one finding was that general floor or ED, but not ICU, location was associated with increased incidence of difficulty/complication.

 

[pgg]

Another video laryngoscope failure today -

Asked by CRNA to come in and be available to help if an airway turned out to be difficult. Bearded man scheduled for "I&D of neck cyst" by ENT. MP3 airway, some neck swelling on the right. I ask ENT to be in the room during induction, and did 6 or 7 solid minutes of preoxygenating while he gets ready. Not really anticipating anything especially difficult.

McGrath in room as plan B. He induces (propofol & succ), DLs with a MAC 4, poor view, unable to pass tube.

McGrath in, I see over his shoulder that the epiglottis looks wrong, sort of folded over on itself, kind of pushed up against posterior wall of hypopharynx. At best a grade IV view, one aretynoid is large ... now we're thinking tumor not cyst or abscess. Unable to pass tube. Unable to pass bougie.

Not too difficult to ventilate patient with OP airway. With the beard, a good mask seal needed two hands. We decide not to wake him up at this point, reasoning that a) we can ventilate, b) an asleep FOI will be easier than an awake FOI.

So I attempt with a fiberoptic bronchscope. Couldn't get around epiglottis.

ENT surgeon tries with scope. Can't get around epiglottis. Getting bloody. We start seriously talking trach ... he gives it a try with a rigid bronchoscope, can't get around epiglottis. Really bloody now, very very difficult to ventilate patient now.

ENT trach'd him in a hurry.

 

[Arcan57]

EDIT: Also, there's another article by the same PI looking at emergent non-operative intubations. Interestingly, one finding was that general floor or ED, but not ICU, location was associated with increased incidence of difficulty/complication.

Not terribly suprising. Nobody that's anticipated to lose their airway is on the floor, and they may or may not have been kept NPO. Regarding the ED, you're going to be taking all comers, have more airway compromise secondary to trauma, and probably have had multiple people attempt the airway prior to anesthesia arriving. The NEAR registry has been pumping out studies looking at ED intubation, they are easy to Google if you're interested.

 

[proman]

Not terribly suprising. Nobody that's anticipated to lose their airway is on the floor, and they may or may not have been kept NPO.

You're kidding right? I've intubated 500 pounders needing full support BiPAP on the floor. Once the airway is difficult I'd rather treat alive aspiration than a hypoxic cardiac arrest in a difficult airway.

 

[NateintheED]

Agree 100%. The glidescope is great but I am not convinced it is a deal breaker and I don't think anyone should rely on it as a rock-solid rescue device. We could sit here all day and bore the EM folks with tales of hairy airways but from my perspective the take home message as an anesthesiologist is that it is a faulty assumption to think that the glidescope is going to bail you out of every bad situation.

I'm coming a little late to this discussion, but I totally agree. I had an airway a couple years ago that I had a great view with the glidescope, but just couldn't get the tube pass, I think because the guy was SO VERY anterior. Luckily it was a semi-elective tube in the ICU and I could bag just fine and had the luxury of waking the pt up (pt was being transferred via air and accepting facility wanted tubed for transport).

Retrospect says I got bad advice from the CRNA (told to use the regular ETT stylet instead of the rigid Glidescope stylet) who was my backup (I was a senior EM resident at the time). Also could've tried placing an Eschmann with the glidescope then passing a tube.

Also, bear in mind that some ED's don't have a glidescope. The place I worked before my current shop had DL, LMA, bougie and a knife. That was IT. And unless there was something actively going on in the OR or L&D, anesthesia was not in-house. Made me VERY nervous when the lady with known shellfish anaphylaxis walked in stridorous with angioedema of her entire face. Luckily the epi worked in time. Otherwise it would have been one DL look, then a cric.

 

[Arch Guillotti]

Retrospect says I got bad advice from the CRNA (told to use the regular ETT stylet instead of the rigid Glidescope stylet) who was my backup (I was a senior EM resident at the time). Also could've tried placing an Eschmann with the glidescope then passing a tube.

CRNA sounds terrible. If the CRNA was there with you, they should have helped to find an alternative way to get the tube in. If they weren't there, then they should have been once there was difficulty with the intubation.

There is no shame in waking up a patient if the circumstances dictate it. Discretion is the better part of valor sometimes.

 

[Arcan57]

You're kidding right? I've intubated 500 pounders needing full support BiPAP on the floor. Once the airway is difficult I'd rather treat alive aspiration than a hypoxic cardiac arrest in a difficult airway.

I was stating that unanticapted decline in respiratory status on the floor (with the usual delay in recognition and activation of airway/code team) and the fact that there is uncertain NPO status (which means they vomit when their stomach is fully insufflated due to over-vigorous yet ineffective BVM technique) makes floor intubations more difficult then ICU intubations. Not sure what your comment regarding choosing aspiration over cardiac arrest is addressing.

BTW, I've never worked at a hospital where Bi-level ventilation went to the floor. My current shop sends anything more then CPAP for people with known OSA to the unit.

 

[NateintheED]

CRNA sounds terrible. If the CRNA was there with you, they should have helped to find an alternative way to get the tube in. If they weren't there, then they should have been once there was difficulty with the intubation.

There is no shame in waking up a patient if the circumstances dictate it. Discretion is the better part of valor sometimes.

Not sure if I'd say the CRNA was terrible, just maybe not too familiar with the glidescope? We didn't rotate through anesthesia at our home institution since they had a CRNA training program and there weren't enough cases to go around, so not sure if they even had one in the OR. The one in the ICU was pretty new.

Actually, the CRNA showed some pretty good restraint in non hip-checking me off that airway. I actually got called up from the ED to do it since anesthesia wasn't available and the IM resident in the ICU was nowhere near comfortable even trying. So by the time the CRNA showed up, I was already well into managing the patient. And we could bag just fine (actually already had done multiple looks w/ Mac and Miller blades and gone to glidescope with bagging in between before any backup showed up). The guys airway was so anterior it just felt like it was on the ceiling!