Fractured mandible and bleeding esophageal varices

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Planktonmd

Planktonmd

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I had this case yesterday:
50 Y/O advnced liver disease, bleeding esophageal varices (required 5 units PRBC over 2 hours), has broken mandible and as a sesult he can open his mouth about 0.5 cm (because of pain and a good size hematoma).
He is alert and oriented.
GI guy wants to do EGD and put bands on his varices, he consulted me because he thinks the guy won't tolerate the procedure without our help.
Oral surgeon wants to take him to OR and fix his mandible in 24-48 hours and he then will need to wire him shut.
Coagulopathy not too bad : INR= 1.8, platelets = 90,000
His thyromental distance is less than 2 cm and has a thick neck.
What's the plan?
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Give him some FFP +/- platelets, then awake nasal fiberoptic. Would probably be best to try to combine both procedures into one, if possible. Be prepared for an awake trach. Also recommend large bore access x2 vs CVC, +a-line, have blood ready to roll.
 
Ideally i would like to do an awake Nasal fiberoptic. Given current Coag/platelet status i have concern about sticking stuff in the nose until those are better corrected. But First talk with GI guys and OMFS about coordinating there procedures so you only have to do it once. Also i would like them to talk because if GI is unable to properly band and really minimize the chance of hemoptysis, then OMFS should seriously consider trach and GI placing NGT and DHT post procedure. The last thing this patient needs is to be extubated on the floor with jaw wired and then start aspirating on blood because he cant spit it out the mouth.
 
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Do EGD with banding with swish, gargle and swallow 4% lidocaine, 1-2mgs of versed and 1-2mls of fentanyl. When the OMFS boys want to roll, awake nasal FOI. Make sure he's doin' calculus when ya pull the ETT. Regards, ----Zippy
 
zippy2u said:
Do EGD with banding with swish, gargle and swallow 4% lidocaine, 1-2mgs of versed and 1-2mls of fentanyl. When the OMFS boys want to roll, awake nasal FOI. Make sure he's doin' calculus when ya pull the ETT. Regards, ----Zippy
Click to expand...
He only can open his mouth 0.5 cm the EGD scope won't fit :)
 
Bah, when no one is lookin' pry open his mouth another 0.5cm and tell him "just a little discomfort, sir" in your best soothing voice---don't be a Nancy boy. Regards, ---Zippy
 
Awake Nasal FOI. Put in a small tube. You can change it later once the coagulopathy is corrected.

Otherwise this would be ideal for a RETROGRADE!
 
4U FFP, awake nasal FOI, if no go trach him. You are going to have to control his airway for the mandible anyway. Try to get the Oral surgeon dudes to fix his mandible when the egd gets done. If they don't want to do it then, keep him intubated if the FOI works until they can get him done. ICU post op if not trached.

Pd4
 
lets say his variceal bleeding is not permanently controlled by the GI intervention. he has his mouth wired shut for the fracture. i think an elective trach is justified in this case. whether it is done before or after he is nasally intubated awake, is the question.
 
Here is what happened:
I decided that he needs his airway secured now for both procedures, the Oral surgeon really wanted to wait 1 -2 days for the edema to decrease and also for the GI bleeding to be hopefully controlled.
He was given FFP and platelets.
We took him to the OR, phenylephrine to the nose, topical anesthesia to the nose and upper airway using atomized 4% Lido.
Transtracheal block.
Inserted the scope as gently as possible in the nose and he starts bleeding and I can't see anything.
I did not want to traumatize the nose too much so I put the FOB in the mouth and intubate without difficulty.
patient goes to sleep and they proceed with the EGD.
At the End I need to switch to nasal tube for the anticipated surgery, how would you do that safely?
 
Plank, first off I'd say at this point the guy should get an elective trach, as astutely mentioned above. At least for the time being, it'll make everyone's life much easier getting thru the recovery process while he's wired shut with the varices maybe only tenuously controlled. Particularly now that his nose is bloody, I FAR favor a trach to a nasal tube.

But... if you just have to swap out that oral ETT for a nasal tube...geez... How bout this jerry-riggage... Drop an exchange wire down the oral ETT but leave the tube in place for the moment. Dry up his nose the very best you can, then go down the least traumatized nare with the fiberoptic scope, with softened nasal tube loaded up but not yet advanced. Drive the scope right down to the cords, and then, while you're watching, have an assistant slowly pull back the oral ETT over the wire until it's just outside the cords but still ready to go back in if necessary. Then, just as the oral ETT backs out of the cords, advance the scope thru the cords and then gently advance the nasal tube thru. Once you've verified placement and you're happy, pull the wire out (before you inflate the cuff), with the idea being that the exchange wire is thin enough that it can also fit thru the cords while getting the nasal tube in, so that in case you can't get the nasal tube in, at least the wire would be there to bail you out if need be. All the while, I'd have him prepped and ready for ENT to do an emergent trach.

Whew! If that isn't enough to convince you to just do the damn trach, I don't know what is! :laugh:
 
you boogered up his airway one time already....you want to try AGAIN?

Planktonmd said:
Here is what happened:
I decided that he needs his airway secured now for both procedures, the Oral surgeon really wanted to wait 1 -2 days for the edema to decrease and also for the GI bleeding to be hopefully controlled.
He was given FFP and platelets.
We took him to the OR, phenylephrine to the nose, topical anesthesia to the nose and upper airway using atomized 4% Lido.
Transtracheal block.
Inserted the scope as gently as possible in the nose and he starts bleeding and I can't see anything.
I did not want to traumatize the nose too much so I put the FOB in the mouth and intubate without difficulty.
patient goes to sleep and they proceed with the EGD.
At the End I need to switch to nasal tube for the anticipated surgery, how would you do that safely?
Click to expand...
 
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Fastrach said:
Plank, first off I'd say at this point the guy should get an elective trach, as astutely mentioned above. At least for the time being, it'll make everyone's life much easier getting thru the recovery process while he's wired shut with the varices maybe only tenuously controlled. Particularly now that his nose is bloody, I FAR favor a trach to a nasal tube.

But... if you just have to swap out that oral ETT for a nasal tube...geez... How bout this jerry-riggage... Drop an exchange wire down the oral ETT but leave the tube in place for the moment. Dry up his nose the very best you can, then go down the least traumatized nare with the fiberoptic scope, with softened nasal tube loaded up but not yet advanced. Drive the scope right down to the cords, and then, while you're watching, have an assistant slowly pull back the oral ETT over the wire until it's just outside the cords but still ready to go back in if necessary. Then, just as the oral ETT backs out of the cords, advance the scope thru the cords and then gently advance the nasal tube thru. Once you've verified placement and you're happy, pull the wire out (before you inflate the cuff), with the idea being that the exchange wire is thin enough that it can also fit thru the cords while getting the nasal tube in, so that in case you can't get the nasal tube in, at least the wire would be there to bail you out if need be. All the while, I'd have him prepped and ready for ENT to do an emergent trach.

Whew! If that isn't enough to convince you to just do the damn trach, I don't know what is! :laugh:
Click to expand...

You don't need to convince me, I actually would love it if every potential difficult airway would get an elective tracheostomy, it would make my life much easier.
But, in real life (which you will experience soon) things are not that simple.
I like your plan for switching the tube but it relies too much on having a good view with the FOB.
 
I think you gave him the best shot at not getting a trach. The scope is not going to do you any good. This guy is going to bleed with whatever you do with his nose, especially if he started bleeding with just the scope. I think its trach time.
 
Trach for sure. Ideally he would be intubated first but awake trach with INR of 1.8 shouldn't be big problem. They can decannulate in 3-6 weeks when they cut his MMF wires and then he's got a cool scar for the ladies...or the scar can easily be revised if the ladies aren't diggin' it.

A trach is never the wrong answer.
 
Planktonmd said:
You don't need to convince me, I actually would love it if every potential difficult airway would get an elective tracheostomy, it would make my life much easier.
But, in real life (which you will experience soon) things are not that simple.
I like your plan for switching the tube but it relies too much on having a good view with the FOB.
Click to expand...

Plank-- Holy geebzus, that must be one b*tch of an OR you're working in if this guy is considered only a "potential" difficult airway! I'm curious, what additional criteria does this guy require in order to meet your definition??
 
Fastrach said:
Plank-- Holy geebzus, that must be one b*tch of an OR you're working in if this guy is considered only a "potential" difficult airway! I'm curious, what additional criteria does this guy require in order to meet your definition??
Click to expand...
As an anesthesiologist you are trained to manage the airway non surgically, this is what you do best, and this is what I do unless I have no choice.
The fact that the patient might need a tracheostomy for his post-op management and recovery period does not necessarily mean that I will require a tracheostomy to anesthetize him, it would be great to have it, but I certainly don't need it to do my job.
 
it's not that you might need a trach for this guy. you DO need a trach for this guy.

as an airway consultant it is up to you to recommend a trach (or whatever you feel he needs) for this patient. ok, you don't need it for your anesthetic, but it is needed for post op, in my opinion.

so instead of reinventing the wheel and trying to exchange one tube for another, just exchange that tube for a nice secure trach.


a trach scar is THE LEAST of this pt's problems.
 
Jeff05 said:
it's not that you might need a trach for this guy. you DO need a trach for this guy.

as an airway consultant it is up to you to recommend a trach (or whatever you feel he needs) for this patient. ok, you don't need it for your anesthetic, but it is needed for post op, in my opinion.

so instead of reinventing the wheel and trying to exchange one tube for another, just exchange that tube for a nice secure trach.


a trach scar is THE LEAST of this pt's problems.
Click to expand...
No I DON"T!
My job here is to provide safe intraop and post op course for this patient, I can achieve that with an ETT but if the physicians taking care of him later feel that he needs a tracheostomy they can do it.
I am not sure what is it that you can do with a tracheostomy that can not be done with an ETT for this patient?
Do you actually believe that the tracheostomy is going to give better airway protection?
Do you think having a tracheostomy is going to prevent him from aspirating blood from his ruptured esophageal varices better than an ETT?
This patient as soon as his GI bleed is controlled can be extubated like any other patient who had a fractured mandible, do you want a tracheostomy on every patient with a broken mandible?
 
I agree with the trach, a nasal tube will give him a sinus infection within three days. Better sooner than latter.
 
Planktonmd said:
This patient as soon as his GI bleed is controlled can be extubated like any other patient who had a fractured mandible, do you want a tracheostomy on every patient with a broken mandible?
Click to expand...

Is he going to breath well with a closed mouth and blood in his nose? maybe...
 
not every patient with a broken mandible should have a trach.

you said he bled a lot when you put a scope as gently as possible in his nose...it is not crazy to think that the same thing may happen as you are gently pulling a tube out of his nose. as your experience goes, you will not be able to reintubate him expediciously.

i would strongly encourage this patient's physicians (i believe you are one of them) to get the trach and document that everywhere. because when they pull that nasal tube with his mouth wired and he starts bleeding or has another variceal bleed - GAME OVER.
 
Jeff05 said:
not every patient with a broken mandible should have a trach.

you said he bled a lot when you put a scope as gently as possible in his nose...it is not crazy to think that the same thing may happen as you are gently pulling a tube out of his nose. as your experience goes, you will not be able to reintubate him expediciously.

i would strongly encourage this patient's physicians (i believe you are one of them) to get the trach and document that everywhere. because when they pull that nasal tube with his mouth wired and he starts bleeding or has another variceal bleed - GAME OVER.
Click to expand...
So you agree that I don't need a tracheostomy now or for the next few days don't you?
You also do agree (I think ) that a tracheostomy is a bit radical if you are doing it because an awake alert patient might have epistaxis on extubation don't you?
Do you think it might be possible that he might just stop bleeding from his esophagus and not need a tracheostomy?
 
Depending on the MELD score and other factors....patients with varices FREQUENTLY rebleed within a few days....

A good number of them die within a few weeks.

One can't be short sighted when treating these patients. Any good CRNA can anesthetize this patient for the case....the planning that goes into the care of this patient beyond 24 hours requires an anesthesiologist.
 
You now have him orally intubated. I'm assuming there is no way that the oral surgeons can fix his mandible with an oral tube. You can take a look with the scope or you can take a look through the mouth with a laryngoscope, if you can see great, to me the problem comes from trying to get a tube through his nose. It bled with just the fiberoptic scope, it is going to bleed and bleed worse with a tube. After stirring up all this bleeding then you are going to have to take out your secure airway and pray the nasal tube goes into the right place with the bloody bubbles. You can do all the tube changer magic you want but I don't trust those things unless I am reasonably sure I could get the tube back in without one. That trach will heal, it will be nonemergent and controlled. I think this is better than the possibility of losing his airway.
 
dhb said:
Is he going to breath well with a closed mouth and blood in his nose? maybe...
Click to expand...
I am assuming that you guys have already done some oral surgery cases and extubated patients who were wired, am I correct?
These patients do bleed from the nose and mouth don't they?
They even vomit sometimes don't they?
What would you do if they have epistaxis or vomit? a tracheostomy?
 
militarymd said:
Depending on the MELD score and other factors....patients with varices FREQUENTLY rebleed within a few days....

A good number of them die within a few weeks.

One can't be short sighted when treating these patients. Any good CRNA can anesthetize this patient for the case....the planning that goes into the care of this patient beyond 24 hours requires an anesthesiologist.
Click to expand...
I am going to willingly ignore your stupid statement.
 
pd4emergence said:
You now have him orally intubated. I'm assuming there is no way that the oral surgeons can fix his mandible with an oral tube. You can take a look with the scope or you can take a look through the mouth with a laryngoscope, if you can see great, to me the problem comes from trying to get a tube through his nose. It bled with just the fiberoptic scope, it is going to bleed and bleed worse with a tube. After stirring up all this bleeding then you are going to have to take out your secure airway and pray the nasal tube goes into the right place with the bloody bubbles. You can do all the tube changer magic you want but I don't trust those things unless I am reasonably sure I could get the tube back in without one. That trach will heal, it will be nonemergent and controlled. I think this is better than the possibility of losing his airway.
Click to expand...
I am not arguing that a tracheostomy is a bad idea, I am saying I can do it without a tracheostomy, and in my hands it is safe.
 
Planktonmd said:
I am not arguing that a tracheostomy is a bad idea, I am saying I can do it without a tracheostomy, and in my hands it is safe .
Click to expand...

You made it bleed once already.....is that how you define "safe"?

and not only did you make it bleed, you had to abandon the procedure....is that also how you define "safe"?
 
I don't think anyone's arguing that you couldn't manage it however you please, Plank. But the issue, I think, is what is going to be best for this pt immediately postop, in the days/weeks afterward, and in the grand scheme of this charlie foxtrot he's mired in. Bravo that you can manage his airway without a trach, but what about the less-skilled folks who may be called upon to manage it while you're not in-house when the **** hits the fan? Or are you offering to become this patient's 24-hr airway manager during his entire perioperative course??
 
of course it is possible. anything is possible. we're just managing risks and benefits in medicine. if i don't beta block the CAD patient is he GOING to have an MI? maybe - BUT, probably NOT, am i still gonna do it - yep, just hoping to mitigate risk. nothing is certain.

in my opinion, this patient has 2 risk factors for having a large amount of blood in the airway (i do extubate jaw fx patients, but they are not grossly coagulopathic) AND another compounding issue that if he does have blood in said airway it would take A LONG TIME to control that airway.



Planktonmd said:
So you agree that I don't need a tracheostomy now or for the next few days don't you?
You also do agree (I think ) that a tracheostomy is a bit radical if you are doing it because an awake alert patient might have epistaxis on extubation don't you?
Do you think it might be possible that he might just stop bleeding from his esophagus and not need a tracheostomy?
Click to expand...
 
Fastrach said:
I don't think anyone's arguing that you couldn't manage it however you please, Plank. But the issue, I think, is what is going to be best for this pt immediately postop, in the days/weeks afterward, and in the grand scheme of this charlie foxtrot he's mired in. Bravo that you can manage his airway without a trach, but what about the less-skilled folks who may be called upon to manage it while you're not in-house when the **** hits the fan? Or are you offering to become this patient's 24-hr airway manager during his entire perioperative course??
Click to expand...
I didn't say let's extubate the guy and leave him with unprotected airway while his varices are still bleeding, I just was saying that a tracheostomy is not a magic solution and there is a chance he might not need it.
The reason why i posted this case is because it is unusual and for me this was the first time I had to deal with this combination: Mandibular fracture + Bleeding esophageal varices. I hope it was beneficial.
 
Planktonmd said:
At the End I need to switch to nasal tube for the anticipated surgery, how would you do that safely?
Click to expand...

I like logistic problems. I'll take a crack.

1. While OETT still in place, insert nasal RAE/nasal wire spiral until in the oral pharynx.
2. Pre-oxygenate
3. Deep mainstem the OETT and place gum bougie in OETT.
4. Remove OETT
5. Thread nasal tube over gum bougie. Done
 
OK Cowboy, tell the CRNA to getcha a pediatric scope, load it with a lubricated 6.5 nasal ETT. Deflate cuff on the oral ETT. Shove scope nasally to mainstem. pull out oral ETT and thread nasal ETT in trachea. Pediatric scope typically won't reactivate the nasal bleeding and the 6.5 nasal ETT will compress what bleeding occurs once in position. Regards, ----Zippy
 
zippy2u said:
OK Cowboy, tell the CRNA to getcha a pediatric scope, load it with a lubricated 6.5 nasal ETT. Deflate cuff on the oral ETT. Shove scope nasally to mainstem. pull out oral ETT and thread nasal ETT in trachea. Pediatric scope typically won't reactivate the nasal bleeding and the 6.5 nasal ETT will compress what bleeding occurs once in position. Regards, ----Zippy
Click to expand...
What I did was similar but instead I used the glidescope since I can now open the mouth a little more.
I inserted a well lubricated tube changer through the nose and put the glidescope in the mouth and with a mcgill I directed the changer through the cords and a few centimeters down, then I pulled the oral ETT slowly under direct vision and advanced the nasal tube over the changer and through the cords.
He bled a little but as you said the tube compressed it.
It worked great.
But I guess it doesn't matter since I should have done a tracheostomy :)
 
I actually think it was not a good idea to change over the oral tube to nasal tube. I don't disagree that a trach would probably be needed down the line, but why not leave the patient orally intubated until the day of mandibular surgery? Oral tube is larger (easier to ventilate), less likely to cause an infection (sinus), and the extra day may give the nose a rest so it will be less likely to bleed when you try fiberoptic again. I think the experience of the tube exchange benefited you more than the patient.
 
achieman said:
I actually think it was not a good idea to change over the oral tube to nasal tube. I don't disagree that a trach would probably be needed down the line, but why not leave the patient orally intubated until the day of mandibular surgery? Oral tube is larger (easier to ventilate), less likely to cause an infection (sinus), and the extra day may give the nose a rest so it will be less likely to bleed when you try fiberoptic again. I think the experience of the tube exchange benefited you more than the patient.
Click to expand...
Leaving him intubated orally means that someone else might have to deal with the airway issue at the time of the surgery, It's not nice to leave unfinished business to your partners.
 
Planktonmd said:
I am not arguing that a tracheostomy is a bad idea, I am saying I can do it without a tracheostomy, and in my hands it is safe.
Click to expand...

I humbly disagree with you.

With an already-secured airway, the simplest, safest thing to do is a trach.

Too much stacked against you thats outta your control.......independent of your skills......that could go awry.

Very, very simple. Low risk.

More risk removing oral tube and putting it back in the nasal route.

Blood is your enemy when you're using a fiberoptic-something (bronchoscope, glidescope, etc)

What if a varices blows at the wrong time? What if his nose bleeds alot? Etc etc

No need to tie yourself up doing all this.

Call the ENT dude.

He'll probably even do it on the stretcher.

And this problem has evaporated.
 
jetproppilot said:
Yes it is.
Click to expand...
Jet,
I absolutely see where you are coming from, but as you know, in this business there is always several ways to do everything.
I have sufficiently explained my reasoning for managing the patient the way I did, many disagreed, and that is ok, the bottom line is I hope everyone who participated did benefit from the discussion, I know I did.
The combination of bleeding esophageal varices and a broken jaw is not a common one and I doubt many people have preformulated plans to handle it, so I hope our discussion here stimulated some thinking.
 
Planktonmd said:
Jet,
I absolutely see where you are coming from, but as you know, in this business there is always several ways to do everything.
I have sufficiently explained my reasoning for managing the patient the way I did, many disagreed, and that is ok, the bottom line is I hope everyone who participated did benefit from the discussion, I know I did.
The combination of bleeding esophageal varices and a broken jaw is not a common one and I doubt many people have preformulated plans to handle it, so I hope our discussion here stimulated some thinking.
Click to expand...

Absolutely!

Well said.

Great thread.
 
How come no one wanted to send this guy to have a tips done....easy and with local...and better than bands.
 
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