First Bad Airway As An Attending.

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canigetawhatwhat

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Story Time!

I live in a VERY unhealthy part of the country. I intubate 1-2 a week in a rural setting. New grad. I learned with Glidescope but I became a DL king and swear to myself that Glidescope is a backup. As an attending, I've tubed +30 in 6 months. 25 DL 1st attempt. 4 DL 2nd attempt. 1 Bougie 2nd attempt. This was the first one to make me sweat....
So I primarily work in centers with back up (never called them).....but this time I was working in a 6 bed single coverage ER with Me only. Had a guy come in with a CO2 of 120+. Obtunded. Luckily still oxygenating. Me and 2 nurses. RT is older than Betty White. Took out my personal bougie. Pre-ox with NRB. Bags well. First look, DL. Lots of snaggle teeth. Small mouth, Limited Flexion of neck, lots of facial swelling, tight mouth due to swelling. Blade goes in, with cricoid pressure, I get a grade 3 and a 1/2 look. Immediately abort and set up Glidescope. Got a grade 2 with glidescope, unfortunately tight mouth + big ass glidescope blade = cant get tube in. So pull out my personal bougie (!) (small hospital doesnt have one) and use bougie glidescope. Very anterior. With some luck, I bounce the bougie in and right mainstem it. Put the tube in over it but it doesnt thread due to redundant tissue. I bagged him only once in between the DL and the glidescope, now he starts to desat. Cant get it in. Starts to bleed and some vomit come up. Shove my fingers in and just lift all redundant tissue. No dice. Pull out glidescope blade and shove 4 fingers in. Lift all redundant tissue and finally it threads. Crisis averted. Shipped to tertiary center.

Thankfully the RT went up to the OR afterwards to replace my personal bougie.

Moral of story, despite being a new age cavalier, it's good to always have back ups. Made it to my third back up, and managed to snag it. Probably should of ketamine'd him in retrospect but whatev.
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I'm a fan of bougie first time, every time.

That plus bimanual laryngoscopy FTW.
 
Last edited:
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I'm here to sell you a drug called cricolol...

I really hope you accidentally wrote cricoid pressure but meant to say bimanual laryngoscopy.
 
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canigetawhatwhat said:
Story Time!

I live in a VERY unhealthy part of the country. I intubate 1-2 a week in a rural setting. New grad. I learned with Glidescope but I became a DL king and swear to myself that Glidescope is a backup. As an attending, I've tubed +30 in 6 months. 25 DL 1st attempt. 4 DL 2nd attempt. 1 Bougie 2nd attempt. This was the first one to make me sweat....
So I primarily work in centers with back up (never called them).....but this time I was working in a 6 bed single coverage ER with Me only. Had a guy come in with a CO2 of 120+. Obtunded. Luckily still oxygenating. Me and 2 nurses. RT is older than Betty White. Took out my personal bougie. Pre-ox with NRB. Bags well. First look, DL. Lots of snaggle teeth. Small mouth, Limited Flexion of neck, lots of facial swelling, tight mouth due to swelling. Blade goes in, with cricoid pressure, I get a grade 3 and a 1/2 look. Immediately abort and set up Glidescope. Got a grade 2 with glidescope, unfortunately tight mouth + big ass glidescope blade = cant get tube in. So pull out my personal bougie (!) (small hospital doesnt have one) and use bougie glidescope. Very anterior. With some luck, I bounce the bougie in and right mainstem it. Put the tube in over it but it doesnt thread due to redundant tissue. I bagged him only once in between the DL and the glidescope, now he starts to desat. Cant get it in. Starts to bleed and some vomit come up. Shove my fingers in and just lift all redundant tissue. No dice. Pull out glidescope blade and shove 4 fingers in. Lift all redundant tissue and finally it threads. Crisis averted. Shipped to tertiary center.

Thankfully the RT went up to the OR afterwards to replace my personal bougie.

Moral of story, despite being a new age cavalier, it's good to always have back ups. Made it to my third back up, and managed to snag it. Probably should of ketamine'd him in retrospect but whatev.
Click to expand...

Good job for not losing your cool and being ready with Plans B through E.

Why would you say in retrospect you would have ketamined him? I assume you don't mean ketamine and paralytic agent, as that would make no difference. You mean ketamine alone to preserve spontaneous respiration? But he bagged easily, so that wouldn't really help.

I appreciate that you don't want to paralyze people you won't be able to ventilate, but for everyone else, paralysis will give you the best possible chance of success.
 
Good job.

Half of the battle is identifying troublesome airways before you start, you can "cheat" and to ketamine + glidescope, etc up front.

The OTHER half is remembering that ANY airway can become a cluster at ANY time. Thus you need to have your backups and adjuvants ready, and your mind calm and prepared to go down your algorithm.

I do keep a pocket bougie in my pants pocket for just this type of situation. Also as a talisman of good luck :)
 
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So logistics of carrying bougie in your pocket routinely... Not too big/combersome? I assume you have it knotted around itself like a pretzel, it doesn't loose it's shape after a while?
 
sum dude said:
HIGHLY recommend Delayed sequence intubation on these guys--saved my butt on a similar case (good use of Ketamine)
https://emcrit.org/dsi/
Click to expand...
I'm all for DSI with patients who are hypoxic and combative, or so anxious that they won't take normal breaths etc, but I don't see how it would help with this guy. He was "obtunded but still oxygenating." Throw a NRB on him with a NC for passive oxygenation and he's a perfect RSI candidate. What's the benefit of DSI here?
 
engineeredout said:
So logistics of carrying bougie in your pocket routinely... Not too big/combersome? I assume you have it knotted around itself like a pretzel, it doesn't loose it's shape after a while?
Click to expand...

I keep one in my bag. It is curled up but i can straighten it out in a minute.
 
We have copious bougies in our ED, and I keep one in my bag (which is under my desk, so easy to get to).

But I have a pocket bougie which fits in a cargo pocket no problem. Sadly I've transitioned to the ED Mullet with cargos... the things I carry are too useful...

Left pockets are the "OH CRAP" pockets, mostly useful in surprise situations or if called to the floor/ICU where supplies are lacking:
-Pocket bougie
-PEEP valve
-Couple #11 blades
-Couple 14g/16g Angios
-Nasal atomizer
-Big tourniquet (like the military style, not the blood-draw things)
-Skin Marker
Now admittedly, I use the scalpels and skin marker out of this pocket routinely instead of finding one in the ED.

Right pockets are the "need it all the time, never in the room / hallway bed" pockets:
-Hemeoccult developer and stack of cards
-tongue blade
-Long Qtips
-LeatherMan folding trauma sheers (also ring cutter)... the best thing ever.
 
Janders said:
-LeatherMan folding trauma sheers (also ring cutter)... the best thing ever.
Click to expand...
+1 for Leatherman raptor. The ring cutter is legit.

For all the ketamine love, I think it's important to be clear about what it does and doesn't buy you.
Control of agitation - check
disassociation -check
preserved airway/breathing - check
easy intubation using it as solo agent - nope

Those preserved airway reflexes that give us the warm fuzzies when we're doing procedural sedation mean that a ketamine only intubation is still a challenge. If you're using it to control agitation so you can topicalize an airway and you have the time for it (worsening but non-critical angioedema is probably poster child for this scenario) then sure. If you're tossing ketamine at them and then charging in with a Mac or Glidescope then a lot of times all the ketamine will do is give you enough time to thoroughly FUBAR the airway before you move to plan B. A gagging/hyper-salivating airway is not a friendly airway and your best chance to avoid cutting the neck is going to be optimizing everything on the first try. As much as we want it to be, a ketamine only intubation has nowhere near the success of an RSI airway and depending on how much edema and bleeding you kick up on the first try it may change an airway you could have gotten into a failed airway when you finally convert to RSI.
 
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Arcan57 said:
+1 for Leatherman raptor. The ring cutter is legit.

For all the ketamine love, I think it's important to be clear about what it does and doesn't buy you.
Control of agitation - check
disassociation -check
preserved airway/breathing - check
easy intubation using it as solo agent - nope

Those preserved airway reflexes that give us the warm fuzzies when we're doing procedural sedation mean that a ketamine only intubation is still a challenge. If you're using it to control agitation so you can topicalize an airway and you have the time for it (worsening but non-critical angioedema is probably poster child for this scenario) then sure. If you're tossing ketamine at them and then charging in with a Mac or Glidescope then a lot of times all the ketamine will do is give you enough time to thoroughly FUBAR the airway before you move to plan B. A gagging/hyper-salivating airway is not a friendly airway and your best chance to avoid cutting the neck is going to be optimizing everything on the first try. As much as we want it to be, a ketamine only intubation has nowhere near the success of an RSI airway and depending on how much edema and bleeding you kick up on the first try it may change an airway you could have gotten into a failed airway when you finally convert to RSI.
Click to expand...

Yep.

Ketamine dissociation can anxiolyse an otherwise awake intubation, but you need topical anesthesia for these to go well. In my experience that takes at least 15 minutes from glycopyrrolate to plastic, usually more like 30 minutes.

Awake nasal ketamine-only intubations are just the thing for your predictably difficult, sick-but-not-crashing tubes. But man, they are a hassle to actually do right.
 
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Anecdotally I have different experiences with ketamine and intubation.
I use is a ton in septic, asthmatic, etc. for 9 years since residency. I have not seen appreciable salivation to the extent it makes the intubation difficult.
Only a handful of times have I needed to use suction for what I attributed to the ketamine and this was with folks I found I needed to dose quite high for whatever reason. I never use glyco.
 
Why not just use ketamine + rocuronium + glidescope?

Of course hindsight is 20/20, but here goes:
you may have had a clearer view
he might not have vomited
Tight mouths become less tight --> don't need to position/crank mouth open as much --> less bleeding
if I were being intubated, I'd want someone using the glidescope.

In my book DL should be a backup for glidescope --> when the screen fails. DL shouldn't be a brag-point for the cavalier ego.

And all the old guys who don't know how to use a glidescope should learn PDQ. Of course if you're that technology incompetent, you're probably not reading this forum.

2cents.
 
TrumpetDoc said:
Anecdotally I have different experiences with ketamine and intubation.
I use is a ton in septic, asthmatic, etc. for 9 years since residency. I have not seen appreciable salivation to the extent it makes the intubation difficult.
Only a handful of times have I needed to use suction for what I attributed to the ketamine and this was with folks I found I needed to dose quite high for whatever reason. I never use glyco.
Click to expand...

Just to be clear, I use the glycopyrrolate to facilitate topical anesthesia in "awake" intubations. Not to counteract ketamine.
 
WilcoWorld said:
Just to be clear, I use the glycopyrrolate to facilitate topical anesthesia in "awake" intubations. Not to counteract ketamine.
Click to expand...

don't think I read the nuance of your statement.
I have not used it for that.

Do you see an appreciable improvement in topical anesthetics with glyco before?
 
TrumpetDoc said:
don't think I read the nuance of your statement.
I have not used it for that.

Do you see an appreciable improvement in topical anesthetics with glyco before?
Click to expand...

I have seen a marked improvement in the patient's tolerance for airway manipulation.

But if I'm honest with myself I have to admit that I can't be sure if this is actually due to the glyco, or simply due to the fact that those were the cases where I really took my time and gave all of the steps enough time to work.
 
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im no cowboy with airways. if im worried i call for backup. my last airway was a trauma, guy hit by car flew 60 ft intoxicated, obvious head trauma. gcs 8. attempted intubation for airway protection, PA no go, me no go with glidescope and boigie, could not visualize glottis significant edema. A 2nd doc also could not pass or see cords either. i was prepping the neck when we got a king placed with good ventilation and oxygenation. guy went to the OR, anethesia could not place definitive, got a trach. No reason to be caviliar.

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shoal007 said:
im no cowboy with airways. if im worried i call for backup. my last airway was a trauma, guy hit by car flew 60 ft intoxicated, obvious head trauma. gcs 8. attempted intubation for airway protection, PA no go, me no go with glidescope and boigie, could not visualize glottis significant edema. A 2nd doc also could not pass or see cords either. i was prepping the neck when we got a king placed with good ventilation and oxygenation. guy went to the OR, anethesia could not place definitive, got a trach. No reason to be caviliar.

Sent from my Pixel using Tapatalk
Click to expand...
Lesson: As long as you can ventilate, you probably have time.

If you're working in the facility that will provide definitive management for the patient (i.e. going to your OR), there's a good chance a King/LMA/whatever is sufficient.

If you're about to ship 40 minutes by ambulance, that's potentially a different discussion.
 
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canigetawhatwhat said:
Glidescope. Got a grade 2 with glidescope, unfortunately tight mouth + big ass glidescope blade = cant get tube in. So pull out my personal bougie (!) (small hospital doesnt have one) and use bougie glidescope. Very anterior. With some luck, I bounce the bougie in and right mainstem it. Put the tube in over it but it doesnt thread due to redundant tissue. Cant get it in. Starts to bleed and some vomit come up. Shove my fingers in and just lift all redundant tissue. No dice. Pull out glidescope blade and shove 4 fingers in. Lift all redundant tissue and finally it threads. Crisis averted. Shipped to tertiary center.
Click to expand...

Was the end of your ETT and balloon goopy with lubricant? (if not -- always)
After lubrication, did you rotate the ETT 90 and then 180 degrees? -- to slide over the "cartilages"?
...before sticking my hand in there, I would remove the Glidescope and insert a Mac 3/4 and then slide the ETT over the bougie. (general note: once the bougie is between the cords, always keep the DL blade in position and with "tension")

BoardingDoc said:
I'm all for DSI with patients who are hypoxic and combative, or so anxious that they won't take normal breaths etc, but I don't see how it would help with this guy. He was "obtunded but still oxygenating." Throw a NRB on him with a NC for passive oxygenation and he's a perfect RSI candidate. What's the benefit of DSI here?
Click to expand...

Yeah, no need for DSI as described by EMCrit here. Probably no need for ketamine here. (see Arcan57's post above)
However, there may have been a role for delayed intubation (not DSI and without ketamine). A guy with a pCO2 120 and "oxygenating well" with CO2 narcosis may benefit from 'deylaying' your intubation and starting BiPap. Supporting spontaneous ventilation will drop your pCO2 and increase your pH. This will also give you better "pre-oxygenation" than NRB. Likely a more hemodynamically stable RSI/DSI when the time comes. If you have the time to get an ABG (ie know what his pCO2 is), you have time to "delay" and think of a better plan.

Of course it easy for me to say this as a monday morning QB, but consideration of MMQB advice makes Sundays easier.

HH
 
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DSI is just pre-oxygenation with sedation to make it tolerable), if he's so obtunded he tolerates BIPAP than fine. No one will die from hypercarbia, but they will die from low O2 reserves if you try RSI and it gets delayed. It's not RSI if you are pre-oxygenating them for 15 minutes (which sounds like right move
 
Even if you ignore the impending respiratory failure as a secondary cause, the acidosis can sometimes cause arrhythmias that then cause death.
 
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Dr.McNinja said:
Even if you ignore the impending respiratory failure as a secondary cause, the acidosis can sometimes cause arrhythmias that then cause death.
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This seems dubious. Think about apnea tests for brain death. You throw on a t-piece, give 100% O2, and provide no ventilation. Following ABG's every few minutes, I've had the CO2 rise from 40 to 100 over 15 minutes, without any arrhythmia/ectopy. I realize this is anecdotal, but this is a standard test. This is done on technically still alive people. If it was an incredibly dangerous test and induced appreciable amounts of arrhythmia, I doubt it would be recommended.
 
Just a thought....instead of 15 mins of pre oxygenation with a NRB hook up Bipap with 100 percent fio2 and peep over an oral airway. You may find that 20 mins later you have moved far enough in the right direction not to tube or transport on nippv.

I have become a huge fan of Bipap for lower respiratory issues.

Yeah, there is the taught in residency charge to secure the airway but sometimes discretion is the better part of valor.

Besides, unless you are going to try an feed an obtunded guy a snack pack your blade probably represents a bigger aspiration risk than he has just laying there.
 
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Old_Mil said:
Just a thought....instead of 15 mins of pre oxygenation with a NRB hook up Bipap with 100 percent fio2 and peep over an oral airway. You may find that 20 mins later you have moved far enough in the right direction not to tube or transport on nippv.

I have become a huge fan of Bipap for lower respiratory issues.

Yeah, there is the taught in residency charge to secure the airway but sometimes discretion is the better part of valor.

Besides, unless you are going to try an feed an obtunded guy a snack pack your blade probably represents a bigger aspiration risk than he has just laying there.
Click to expand...

Not sure about where you work but at my critical access shop where just about anything goes, bipap in an altered patient who is otherwise full code not about to be intubated gets a big no from RT and RNs
 
migm said:
Not sure about where you work but at my critical access shop where just about anything goes, bipap in an altered patient who is otherwise full code not about to be intubated gets a big no from RT and RNs
Click to expand...

We do that sometimes, especially on suspected hypercarbic patient. Although I am sitting in the room with them, ready to tube them if needed.

Sometimes if you blow off some of that co2, they suddenly wake up enough to actually tolerate bipap properly. It can change their course from icu with a difficult wean to stepdown...maybe even floor in a day or two.

I have got it to work with a fair number of flash pulmonary edema pts too.

Seems pretty common here...and we are a pretty big level one.
 
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Dr.McNinja said:
Why? Because they just don't want to?
Click to expand...

The quoted concern is for aspiration - ie patient is not conscious enough to remove the mask or let us know they're about to toss their cookies
 
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