Home page for ER AW

[sevoflurane]

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I've enjoyed the "overhead page for ER AW" thread. Good case to go over in case you ever encounter this in the middle of the night like UTSW did. Failing to prepare is preparing to fail right? 🙂

So I thought I might contribute a little on AW management and write a little bit about my case last night. I'll call it: "Home page for ER AW."

So my wife and I are curled up next to the fire watching some good ‘ol xmas classics on the tube. Popcorn is out, good flicks, and I have the good peaceful feeling going on.... Except...I'm on call. So.....

I get a page and it's the ED physician. He says he has a self inflicted GSW with an entrance wound under the mandible. He says he is on a non-rebreather and he thinks he's going to need my help soon. Patient is uncooperative.

What questions do you ask the ED physician as you slap on your scrubs and while you still have him on the phone?

 

[cincincyreds]

Where is ENT?

 

[sevoflurane]

Where is ENT?

45 minutes out. I can be there in 10 minutes.

Good question. Anything else?

 

[DreamLover]

45 minutes out. I can be there in 10 minutes.

Good question. Anything else?

What is his condition? VSs etc.

Is he responsive? Protecting his airway etc.

Is he moving air? Bilateral Breath Sounds etc.

What does he look like? Is he large, small, obese, is his madnible still attached etc.

I can think of lots of questions...you know that the surgeon's on their way, ask for whatever airway equipment that you would like to be at bedside, I'm assuming RT is there already, since it's great to have an extra hands...just be prepared

In my personal experience in a VERY similar situation, GSW from underneath chin out back of head, I was in the trauma bay (trauama surgeon present to do cric if needed), pt was minimally responsive but making a resp effort, I just put a mac 4 in, suction suction suction, God blessed me with an air bubble through the blood, I passed the bougie straight toward the air bubbles and voila....lucky

 

[Surfer]

Most importantly... Where is the exit wound?

 

[pgg]

If ENT is far away, is there a general surgeon in house that can wield a knife? I prefer to defer to a surgeon of some flavor when it comes to surgical airways.

I've looked at the pictures in Netter, but most PGY2 surgery residents have done more neck cutting than I have. I'd hate to think I could wind up doing a surgical airway in the ER while some general surgeon is dictating a hernia op report around a mouthful of donut one floor above me.


It'd be nice if someone could roll our difficult airway cart to the ER while I'm driving.


I'm not sure there's any information he can provide that will help me prepare en route, since I'm making the trip regardless. I'd let him get off the phone and back to the patient. 🙂

 

[Arch Guillotti]

I'm not sure there's any information he can provide that will help me prepare en route, since I'm making the trip regardless. I'd let him get off the phone and back to the patient. 🙂

yeah any long conversation seems just like wasting time to me since you know you are going in.

 

[IlDestriero]

I've had this case 3 times when I was at my crappy little hospital thanks to the helipad. Apparently the protocol is- crashing midair on way to trauma center = land at closest pad. Yeah! We were about 1 step more capable than an ASC, but we had a helipad.
One time, the first time, I watched the ED doc fumble with, and probably go through the trachea with the cric kit. I don't really know, but it wasn't in the trachea.
ENT wasn't coming, as there was no ENT on staff. All 3 times the surgeon was placing lines. (read- not touching the airway with a 10' pole.)
All 3 got surgical cricothyroidotomies with a 5 or 6 cuffed tube, trimmed and sewn in place.
Splash betadyne, vertical incision over CT membrane, small horizontal incision through membrane, pinkey tip dilation, ETT, done.
The crusty old EM chief there "watching" the younger EM guy fumble and get hip checked out gave me the biggest compliment of my career.
After securing the airway, while I was sewing the tube in place, he says, "Nice... How many times have you done that?"
I said "Once, if you count a pig trachea."
He gave me the nod and said... "You're hardcore, man."👍
End result, all 3 stabilized, using most of our available blood products🙄, all 3 dead after transferring them to the trauma center. But, when the time comes to cut someone's neck when I can't intubate or ventilate, they're going to get cut, and they're not going to die.
Everyone needs to take a difficult airway course. When the time comes, there's no time to second guess your ability while the patient is quickly becoming a vegetable.
Of note all 3 pts blew their mandible to shreds and there was no way anything was going in from above, as it looked like a bomb went off in their mouth- shredded tongue, random bone and teeth, and blood clots of course.

 

[sevoflurane]

I've had this case 3 times when I was at my crappy little hospital thanks to the helipad. Apparently the protocol is- crashing midair on way to trauma center = land at closest pad. Yeah! We were about 1 step more capable than an ASC, but we had a helipad.
One time, the first time, I watched the ED doc fumble with, and probably go through the trachea with the cric kit. I don't really know, but it wasn't in the trachea.
ENT wasn't coming, as there was no ENT on staff. All 3 times the surgeon was placing lines. (read- not touching the airway with a 10' pole.)
All 3 got surgical cricothyroidotomies with a 5 or 6 cuffed tube, trimmed and sewn in place.
Splash betadyne, vertical incision over CT membrane, small horizontal incision through membrane, pinkey tip dilation, ETT, done.
The crusty old EM chief there "watching" the younger EM guy fumble and get hip checked out gave me the biggest compliment of my career.
After securing the airway, while I was sewing the tube in place, he says, "Nice... How many times have you done that?"
I said "Once, if you count a pig trachea."
He gave me the nod and said... "You're hardcore, man."👍
End result, all 3 stabilized, using most of our available blood products🙄, all 3 dead after transferring them to the trauma center. But, when the time comes to cut someone's neck when I can't intubate or ventilate, they're going to get cut, and they're not going to die.
Everyone needs to take a difficult airway course. When the time comes, there's no time to second guess your ability while the patient is quickly becoming a vegetable.
Of note all 3 pts blew their mandible to shreds and there was no way anything was going in from above, as it looked like a bomb went off in their mouth- shredded tongue, random bone and teeth, and blood clots of course.

Thanks for sharing and nice job bruh! 😀

 

[sevoflurane]

yeah any long conversation seems just like wasting time to me since you know you are going in.

I dunno home-E's. The way I see it, getting some good info on the phone will mentally prepare me for what to expect when I arrive in the ED. Something as simple as what type of weapon was used makes a big difference to me and my expectations for what I'm going to walk into.

Shotgun means something very different to me than a 9mm round.

Self inflicting shotgun wounds are devastating and can sometimes fail to kill the victim as pressing the trigger on the shotgun directs the pellets anteriorly. I'm surprised pgg didn't mention what kind of gun/caliber round was used/shot. 😉😀

In this case it was a .38

An ED doc will fill you in on important data over a couple of minutes. I find this info invaluable as I get a chance to think about the case when driving into the ED.

 

[Arch Guillotti]

Self inflicting shotgun wounds are devastating and can sometimes fail to kill the victim as pressing the trigger on the shotgun directs the pellets anteriorly. I’m surprised pgg didn’t mention what kind of gun/caliber round was used/shot. 😉😀

Unfortunately I think some folks pulling the trigger have remorse at the last split-second and pull back. If this is an under the jaw shot they just end up shooting off the end of their face.

 

[IlDestriero]

I dunno home-E's. The way I see it, getting some good info on the phone will mentally prepare me for what to expect when I arrive in the ED. Something as simple as what type of weapon was used makes a big difference to me and my expectations for what I'm going to walk into.

Shotgun means something very different to me than a 9mm round.

Self inflicting shotgun wounds are devastating and can sometimes fail to kill the victim as pressing the trigger on the shotgun directs the pellets anteriorly. I'm surprised pgg didn't mention what kind of gun/caliber round was used/shot. 😉😀

An ED doc will fill you in on important data over a couple of minutes. I find this info invaluable as I get a chance to think about the case when driving into the ED.

They were somewhere between door number 1, and door number 2.
I was going to post a photo, but thought better of it.😉
When I did a month of plastics, back in the day, we took cars of a guy like no. 1. Flaps, grafts, etc. All he had was 1/2 a tongue. All because his high school girlfriend dumped him. Of course, he lived. With no eyes, no nose, 1/2 a tongue, and one bad ear.

-what happened to shot gun guy?-

 

[sevoflurane]

What is his condition? VSs etc.

Is he responsive? Protecting his airway etc.

Is he moving air? Bilateral Breath Sounds etc.

What does he look like? Is he large, small, obese, is his mandible still attached etc.

Nice. 👍 This is my approach.

An ED physician calls all specialties all day long.... they can sum up a good synopsis of what’s going on in a couple of minutes or less. You can then ask directed questions that will paint a good picture of severity and potential hazards that may affect patient outcome. Additionally, I think you don’t waste time once you arrive to the ED... especially with an emergent airway unfolding.

So this is what I get in a 3 minute conversation as I’m pulling out of the driveway:

Friendly ED physician:

Hey Sevo, I think I’m going to need your help (love this guy... very cool and collected.. but you can tell something is not right).

I have a 55 y/o patient with a self inflicted GSW . He is a dialysis patient with DM, COPD with ATC 02, h/o CAD s/p CABG and valve replacement, CHF, pacer dependent, AAA, who is combative with a GCS of 9 and + for ETOH.

What are his vital signs Dr. friendly ED guy?

Sats are btw 75% and 88% BP 188/110 He’s not looking good.

Is he moving air?

Yes. But he can’t lay supine. He’s choking on his own blood.

Is there a vascular injury?

I don’t know. He’s bleeding... we are hanging blood.

What type of bullet?

.38 special

Is there an Exit wound?

NO. (nice job Surfer... if the exit wound was out way anterior or lateral I’d be a tiny little bit more relaxed VS. exit wound above the ears.... more importantly for me... where is the bullet now?)

Do you have any studies? CT’s or X-rays?

No CT. We are getting an Xray.

Thank you friendly ED guy. I’ll see you in 10 minutes.


This conversation didn’t take very long... and I felt a lot more comfortable walking into the ED knowing a little bit of the situation.

ask for whatever airway equipment that you would like to be at bedside....

Yep. All the cavalry was there when I arrived. Surgeon (not ENT), ED physicians, respiratory techs... well you know... a **** ton of people in an ED trauma bay. BUT, I did phone into my OR peeps who were overnight call that night and told them to be there when I arrived with all my goodies.... + I like working with people who know me day in and day out.

 

[sevoflurane]

They were somewhere between door number 1, and door number 2.
I was going to post a photo, but thought better of it.😉
When I did a month of plastics, back in the day, we took cars of a guy like no. 1. Flaps, grafts, etc. All he had was 1/2 a tongue. All because his high school girlfriend dumped him. Of course, he lived. With no eyes, no nose, 1/2 a tongue, and one bad ear.

-what happened to shot gun guy?-

Dude:

You know I like posting pictures on SDN. I'm one of those visual dudes. It's more fun.

 

[WholeLottaGame7]

Nice. 👍 This is my approach.

An ED physician calls all specialties all day long.... they can sum up a good synopsis of what’s going on in a couple of minutes or less. You can then ask directed questions that will paint a good picture of severity and potential hazards that may affect patient outcome. Additionally, I think you don’t waste time once you arrive to the ED... especially with an emergent airway unfolding.

So this is what I get in a 3 minute conversation as I’m pulling out of the driveway:

Friendly ED physician:

Hey Sevo, I think I’m going to need your help (love this guy... very cool and collected.. but you can tell something is not right).

I have a 55 y/o patient with a self inflicted GSW . He is a dialysis patient with DM, COPD with ATC 02, h/o CAD s/p CABG and valve replacement, CHF, pacer dependent, AAA, who is combative with a GCS of 9 and + for ETOH.

What are his vital signs Dr. friendly ED guy?

Sats are btw 75% and 88% BP 188/110 He’s not looking good.

Is he moving air?

Yes. But he can’t lay supine. He’s choking on his own blood.

Is there a vascular injury?

I don’t know. He’s bleeding... we are hanging blood.

What type of bullet?

.38 special

Is there an Exit wound?

NO. (nice job Surfer... if the exit wound was out way anterior or lateral I’d be a tiny little bit more relaxed VS. exit wound above the ears.... more importantly for me... where is the bullet now?)

Do you have any studies? CT’s or X-rays?

No CT. We are getting an Xray.

Thank you friendly ED guy. I’ll see you in 10 minutes.


This conversation didn’t take very long... and I felt a lot more comfortable walking into the ED knowing a little bit of the situation.



Yep. All the cavalry was there when I arrived. Surgeon (not ENT), ED physicians, respiratory techs... well you know... a **** ton of people in an ED trauma bay. BUT, I did phone into my OR peeps who were overnight call that night and told them to be there when I arrived with all my goodies.... + I like working with people who know me day in and day out.

I think my question would be, "Is there a chaplain in-house?" Sweet goodness.

 

[sevoflurane]

I think my question would be, "Is there a chaplain in-house?" Sweet goodness.

Not so sure... but there are a couple of things that are extremely helpful in the ED's report and my management of the patient. 😉

 

[IN2B8R]

I’ve enjoyed the “overhead page for ER AW” thread. Good case to go over in case you ever encounter this in the middle of the night like UTSW did. Failing to prepare is preparing to fail right? 🙂

So I thought I might contribute a little on AW management and write a little bit about my case last night. I’ll call it: “Home page for ER AW.”

So my wife and I are curled up next to the fire watching some good ‘ol xmas classics on the tube. Popcorn is out, good flicks, and I have the good peaceful feeling going on.... Except...I’m on call. So.....

I get a page and it’s the ED physician. He says he has a self inflicted GSW with an entrance wound under the mandible. He says he is on a non-rebreather and he thinks he’s going to need my help soon. Patient is uncooperative.

What questions do you ask the ED physician as you slap on your scrubs and while you still have him on the phone?

Questions I'd ask in the following, relevant order:

1) Insurance coverage?
2) VSS? If so, I'm going through Starbucks drive through window before I have to absorb the ER trauma scene....
3) DNR status?
4) As this was self-inflicted, can we spare a few extra bullets and let'em finish the job?
5) Can they call a younger partner in my group (or maybe an ENT guy) who'd be more willing to part way from the pop corn and the X-mas classic?
6) If all of the above answers still lead to me having to go in, then I'd ask for the following: lots of local, a trach tray, and maybe some Ketamine.

All the while with the above points/management, my thoughts will be on tomorrow's schedule and my time of exit from the OR 😉

 

[sevoflurane]

So you walk into bay 17 after a 10 minute ride of pontification...

The first thing you see is that everyone is wearing their big bird yellow suites+ gloves and a face shield = bloody scene.

Typical...

Too many people for what’s going on here. We need space, but I’ll keep my mouth shut. Need to chill out the room. Bring anxiety down if possible.

While suiting up I asses vitals... dang, this guy is 205/110, sats 75%... He’s also agitated, taking off his non-rebreather + continues to be combative. 🙁

Background noise = you hear a constant suctioning of the patients oropharynx. The tubing disappears behind the wall of staff. How much blood is there... I don’t know...

He needs an AW.😉

He has an entry wound under the chin. I’ve seen bigger, but it’s not small. No exit wound though. Where is that dang bullet. 😕

His face on the right is puffy and actively getting bigger... at a moderate rate... but expanding.

He is def. losing force essence, but he’s also fitting... like the guy who is moving despite the fact that he’s apnic...

This guy may want to live after all.

Right hemi-face is swollen and his now closed eyelid is about 4x -5x it’s normal size and purple.

As an anesthesiologist, what do you do? It's your call....!

(no right answer of course)

 

[sevoflurane]

All the while with the above points/management, my thoughts will be on tomorrow's schedule and my time of exit from the OR 😉

Anesthesia trach = early day. 👍

 

[btbam]

Prep for awake FOI, give ketamine as needed. Have an OR ready to go for a trach. Take a look, if no dice, immediately to OR...probably have a cric kit next to you in case he crumps before/during AFOI.

 

[sevoflurane]

Prep for awake FOI, give ketamine as needed. Have an OR ready to go for a trach. Take a look, if no dice, immediately to OR...probably have a cric kit next to you in case he crumps before/during AFOI.

AFOI? He's combative at baseline. You think katamine will do the trick? His sats are not great.

Do you think he'll hold still for local circ/trach?

I'm not so sure. 🙂

 

[sevoflurane]

Sounds pretty silly I know... but

What else do you want to do before you secure his AW?

 

[Idiopathic]

wouldnt mind seeing an xray of the cspine, he could also have tracheal disruption depending on the angle of entry (could also theoretically be mediastinal although it doesnt sound like thats the case), look for air coming from the entry wound, if its high enough im not too worried about the distal trachea

IMO hes getting a crike +/- ketamine/fentanyl/versed followed by conversion to formal trach in the daylight hours, he will probably need vascular surgery and maybe neurosurgery

 

[Idiopathic]

i mean id also like to know NPO and beta blocker status, allergies, last dialysis, todays K+, intubation history, aspirin/plavix/coumadin use and last pacer interrogation but that can wait i suppose 😉

 

[imfrankie]

Would anyone abandon heroic efforts? You may answer silently.

I took care of a kid that looked like our model above. After failing the first time with the shotgun, he did it again. Same result. No trip to heaven, just back to the County.

 

[Hamhock]

Forum visitor:

I have NO fiberoptic skills that could handle this situation, but I don't this is the time or place (ruined face/nasopharynx/oropharynx likely), combative, bloody, sats 75%, peri-mortem, trauma.

I'm with the folks above who said ketamine and open cric...airway now, everything else later.

If there is a surgeon, I hand the knife to them...otherwise, I ketamine and cut.

HH

 

[sevoflurane]

So I walk into the ED. I see an individual who is sitting upright. Slightly dusky color. GCS waxing and waning btw 8-10

First thing is first. In case he can hear me, I introduce myself and let him know I'm here to help. I place an oral AW and position a nurse next to the patient with a yankauer in the corner of his oropharynx. Sats immediately start to climb. 75%, 80%, 88% and levels off at 91%... he’s agitated but I get the sense that he is feeling relief from the oral airway and O2 + he’s not choking on his own blood. His color is improving. ETOH is permeating the room.

With a reasonable sat, the general surgeon and I perform an oral AW exam.

Externally, the trachea is midline and thankfully intact. Submandibular entrance wound visible measuring approximately 3”x1.5”. No neck vascular injuries, but I can’t exclude a vascular injury above the neck. He does haver some good edema/hematoma forming from his chin all the way up to his eyelid which is unusually large. Xrays are back. .36 caliber has torn through his mandible, maxilla/zygomatic arch and orbital floor. It appears that the bullet has not violated the cranial vault... it looks to be lodged behind his right eyeball.

Sats still hovering around 91% so we proceed to take out the oral AW and get 2 overhead lights and a flashlight positioned so that we can light up his oropharynx. Open up his mouth and see/feel mandible and maxilla shattered, hard pallet completely dangling in pieces with rows of 2-3 teeth hanging from them. Kinda like when you go DL someone who hasn’t taken out their partial dentures and they suddenly fall out. Same idea. Dangling hard palate all over the place. We can see the tract of the bullet heading cephalad but can’t see the bullets final location on gross examination. I get the sense that before today, this guy is an easy AW.

We try to lay the patient supine from upright. He goes back for about a millisecond before he starts becoming combative again... shaking his head violently from side to side. There is no way this guy is going to let you position himself supine for an awake trach. He starts drowning when supine.

Based on his AW exam, I’m not sure but confident that I can get through the cords, as I’ve been in this situation before.

You trach guys still want to do an awake trach on this dude... in the supine position with some ketamine?

If you were to select for an ETT what would be your approach? Glidescope, DL with Mac/Miller, Nasal, Fiberoptic....? What meds would you use?

 

[sevoflurane]

BTW, I'm pretty sure this guy is maskable with an OA.

 

[cincincyreds]

Luckily I have 24 hour ENT in my hospital. I had one of these and they came by and awake trached the guy. But the most important thing here is not to burn bridges. How about a precedes infusion instead of ketamine which cause a lot of salivation to really muck up an already mucked up airway.

This is the case that goes real bad real fast. And talk about going to the or, this guy doesn't sound stable to be moved 2 feet.

 

[DrBeaker]

Put oral airway back in, place NRB on pt. I'd be hesitant to put positive pressure into his naso/oropharynx with oral airway and bmv, bullet doesn't appear to violate cranial vault, but it might...

How far supine can he go? Could he tolerate being ramped?

If he can, I would try awake glidescope, hoping to get a view by just putting in the glide and not having to displace any submandibular tissue which he wouldn't like since is mandible is jacked up.

The ED mentioned they are hanging blood, but no one mentioned what type of access we have, if any.

Keep talking to the patient.

A little sedation for the awake glide. Slowly titrate in some fentanyl and versed. Or you could give some glyco with your ketamine.

I'm enjoying this, very fun!

 

[Idiopathic]

if you think hes maskable why not put an LMA in and FOI through that. sounds like most all of your trauma is anterior

 

[imfrankie]

Angiocath through cricothyroid membrane to fall back on

 

[sevoflurane]

if you think hes maskable why not put an LMA in and FOI through that. sounds like most all of your trauma is anterior

Awake? Paralyzed? Sedated?

 

[sevoflurane]

How far supine can he go? Could he tolerate being ramped?

Great question. Yes he tolerated a 45 degree ramp.

 

[sevoflurane]

To be precise, it wasn't a ramp, just the head of the bed was brought down to 45 degrees.

 

[btbam]

I am assuming we have adequate IV access? If so, some combo of versed/fentanyl/ketamine will calm anyone no matter how much they are thrashing around.

I still don't see what's wrong with this approach combined with AFOI to at least take a look. If you can get away with taking a look with the glidescope in this scenario that works too. Again, have your emergency goodies next to you and the ENT on standby ready to trach.

 

[sevoflurane]

I am assuming we have adequate IV access? If so, some combo of versed/fentanyl/ketamine will calm anyone no matter how much they are thrashing around.

I still don't see what's wrong with this approach combined with AFOI to at least take a look. If you can get away with taking a look with the glidescope in this scenario that works too. Again, have your emergency goodies next to you and the ENT on standby ready to trach.

Nothing wrong with your approach... My previous response was just to stir up conversation a little. 😀

I must say though... in this situation, there is a fine line between

A) Sedating a combative patient that has a significant amount of etoh on board with versed, fent, and ketamine.

and

B) Thinking you have a sedated patient that is actually apnic or under deep sedation with a stomach full of ETOH and Blood.

Your approach is perfectly acceptable. You can NEVER go wrong with an awake look. Especially on the boards.... 👍

 

[sevoflurane]

IV access is a 20G peripheral and an IO line I didn't trust.

 

[btbam]

Nothing wrong with your approach... My previous response was just to stir up conversation a little. 😀

I must say though... in this situation, there is a fine line between

A) Sedating a combative patient that has a significant amount of etoh on board with versed, fent, and ketamine.

and

B) Thinking you have a sedated patient that is actually apnic or under deep sedation with a stomach full of ETOH and Blood.

Your approach is perfectly acceptable. You can NEVER go wrong with an awake look. Especially on the boards.... 👍

I am just a lowly AA but I thought it would be a fun convo to take part in 🙂

Besides, I'm at a level 1 trauma center so cases like this are not uncommon.

 

[sevoflurane]

As you can see by my photoshopped pic (need to keep this guys privacy), there is No Cric or Trach. IMO, it would have been very hard with this patient under awake and supine conditions.

So my plan was an awake glidescope look with the head of the bed 45 degrees + yankauer suction + 10mg of ketamine and 1mg of versed. I wanted to keep this guy with a protected AW as his stomach appeared to be visibly full.

I didn't opt for an AFOI because with a bloody oropharynx and a mouth full of loose tissue, the fiberoptic would get easily junked up and could take time. We've all done AFOI that didn't go so smooth or took a little longer than expected.

LMA + Fiberoptic may have worked... but again, I think there was a chance it would have been time consuming, the tip of the bronchoscope could've become messy via blood/tissue and I don't know if this guy would have sat still for this... even with moderate to deep sedation.

Nasal intubation would have been a bad idea as this guy could have had a Le Fort 3 fracture/possibly a CSF leak. I've seen nasal trumpets in the brain before. 😱 Not a pretty looking CT.

I was looking for something fast.

Well, I pre-O2ed with an OA. Then I got the small glidescope blade in and within 30 seconds he started thrashing around...🙁 but not before I took a good look around both directly and through the glidescope. I saw epiglottis and what appeared to be a reasonable shot through the cords. This was enough for me. I pulled out and started down my plan B pathway.

I double checked my 20G and made sure it was working. I was satisfied.

I asked my surgeon to get all his Cric/Trach gear ready to go on a nearby Mayo stand.

Since I knew this guy was a dialyisis patient (thanks friendly ED guy) I asked for a K+... it came back 4.1

I then reinserted the oral airway, brought his sats up to 95% with gentle PPV over 3 minutes.

Then went for it: RSI.

Constant suction via helpful nurse, then 10mg of Etomidate and 80mg of sux.

DL X 1 and 5 seconds later ETCO2 and BBS. Followed by 20mg of vec, a prop infusion and packing of his oropharynx.

🙂

[/url]
IMG_1703 by Crazyhorse75, on Flickr[/IMG]

 

[btbam]

As you can see by my photoshopped pic (need to keep this guys privacy), there is No Cric or Trach. IMO, it would have been very hard with this patient under awake and supine conditions.

So my plan was an awake glidescope look with the head of the bed 45 degrees + yankauer suction + 10mg of ketamine and 1mg of versed. I wanted to keep this guy with a protected AW as his stomach appeared to be visibly full.

I didn't opt for an AFOI because with a bloody oropharynx and a mouth full of loose tissue, the fiberoptic would get easily junked up and could take time. We've all done AFOI that didn't go so smooth or took a little longer than expected.

LMA + Fiberoptic may have worked... but again, I think there was a chance it would have been time consuming, the tip of the bronchoscope could've become messy via blood/tissue and I don’t know if this guy would have sat still for this... even with moderate to deep sedation.

Nasal intubation would have been a bad idea as this guy could have had a Le Fort 3 fracture/possibly a CSF leak. I’ve seen nasal trumpets in the brain before. 😱 Not a pretty looking CT.

I was looking for something fast.

Well, I pre-O2ed with an OA. Then I got the small glidescope blade in and within 30 seconds he started thrashing around...🙁 but not before I took a good look around both directly and through the glidescope. I saw epiglottis and what appeared to be a reasonable shot through the cords. This was enough for me. I pulled out and started down my plan B pathway.

I double checked my 20G and made sure it was working. I was satisfied.

I asked my surgeon to get all his Cric/Trach gear ready to go on a nearby Mayo stand.

Since I knew this guy was a dialyisis patient (thanks friendly ED guy) I asked for a K+... it came back 4.1

I then reinserted the oral airway, brought his sats up to 95% with gentle PPV over 3 minutes.

Then went for it: RSI.

Constant suction via helpful nurse, then 10mg of Etomidate and 80mg of sux.

DL X 1 and 5 seconds later ETCO2 and BBS. Followed by 20mg of vec, a prop infusion and packing of his oropharynx.

🙂

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IMG_1703 by Crazyhorse75, on Flickr[/IMG]

👍 very cool, you really gave 20 of vec though?

 

[pgg]

Nice work. 👍

Constant suction via helpful nurse, then 10mg of Etomidate and 80mg of sux.

DL X 1 and 5 seconds later ETCO2 and BBS. Followed by 20mg of vec, a prop infusion and packing of his oropharynx.

I was really hoping urge would post "pent, sux, tube" in this thread and then be proven right. Got 1/2 my wish, anyway. 😀

 

[sevoflurane]

👍 very cool, you really gave 20 of vec though?

Nope ED did. We don't do major trauma. We chopper them out and chopper guys don't like combative patients with ETT's waking up mid flight.

 

[Arch Guillotti]

Nope ED did. We don't do major trauma. We chopper them out and chopper guys don't like combative patients with ETT's waking up mid flight.

Yeah if he gets squirrelly and the tube falls out it would be disastrous.

 

[loveoforganic]

Thanks for posting - very interesting even with little knowledge.

One question - why's there so much apprehension regarding cric's? Unless there's a pyramidal thyroid lobe, it doesn't seem like there's a lot that could go wrong, so long as you have an intact trachea, and aesthetics seem like they would be a still relevant but relatively unimportant concern if o2 sat dropped significantly.

1st year, so if it sounds naive, there's a reason 🙂

 

[Idiopathic]

Thanks for posting - very interesting even with little knowledge.

One question - why's there so much apprehension regarding cric's? Unless there's a pyramidal thyroid lobe, it doesn't seem like there's a lot that could go wrong, so long as you have an intact trachea, and aesthetics seem like they would be a still relevant but relatively unimportant concern if o2 sat dropped significantly.

1st year, so if it sounds naive, there's a reason 🙂

we just dont do them. we are proficient enough with the blade and the scope that we are rarely called upon to do cricothyrotomy. in fact, many of us have never done or seen an emergency crike in a live human.

 

[loveoforganic]

I gotcha. Are emergent surgical airways in general that rarely needed? Or is it that ENT is usually around to do a trach (or some other more desirable surgical airway) if it comes to that?

 

[DrBeaker]

Emergency invasive airways like cric's and trach's are pretty rare. And everyone is on edge when they have to be done, even in a controlled scheduled trach in the OR. When I'm doing a trach in the OR for a big ENT case, I'm definitely on edge.

I helped my senior do an emergent trach in the ER when I was a surg prelim. Guy was found down, anesthesia was called stat. Patient maskable, unresponsive, they tried DL, glide, bougie, but something kept blocking the ETT from going through the cords. Senior and I went to the ER when they called anesthesia stat, and were there when the decision was made to trach him. We had no records at the time, but later found out he had a similar episode and was intubated and subsequently trach'd about 2 years prior. Guide had tracheal stenosis just below the cords.

I haven't done my pig-lab cric yet, supposed to be coming up soon

 

[loveoforganic]

Gotcha, thanks!

 

[cchoukal]

Emergency invasive airways like cric's and trach's are pretty rare. And everyone is on edge when they have to be done, even in a controlled scheduled trach in the OR. When I'm doing a trach in the OR for a big ENT case, I'm definitely on edge.

I helped my senior do an emergent trach in the ER when I was a surg prelim. Guy was found down, anesthesia was called stat. Patient maskable, unresponsive, they tried DL, glide, bougie, but something kept blocking the ETT from going through the cords. Senior and I went to the ER when they called anesthesia stat, and were there when the decision was made to trach him. We had no records at the time, but later found out he had a similar episode and was intubated and subsequently trach'd about 2 years prior. Guide had tracheal stenosis just below the cords.

I haven't done my pig-lab cric yet, supposed to be coming up soon

I've done two. One was as an ICU fellow at a code where a lady with nasopharyngeal CA (c/b trismus and epistaxis) was bleeding into her airway. Still had a pulse, but mouth opening didn't allow a blade, LMA, or OA. R naris packed with tumor. Tried Mask via NPA in the left, and blind left nasal ETT. Started in with the needle to the neck, but couldn't pass the wire. When she lost her pulse, I asked for a blade, made a vertical incision (surprisingly little blood when there's no pulse; must have been getting inadequate CPR). Poked thru the membrane with my finger, followed by a 6.5 ETT.

For the 2nd one, I was an attending and got called in to assist a colleague who had laryngospasm under an LMA. confirmed a good pre-op airway exam, pushed some prop and succ. Still couldn't mask (with LMA or mask). Tried a host of blades/glides, no view. SpO2 50, blade, finger, tube. When the ENTs came to formalize the trach, they commented that all his tissues were fibrosed and "weird," as if he'd had radiation, although he wsa young and had no known history.

Both were relatively straightforward (whatever that means for a rare, emergency procedure). I can't exactly give any advice based on this, but I guess it's good to practice them, even on cadavers/pigs/mannequins.