ICU intubation scenario

[excalibur]

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This scenario is geared more toward the med students and interns/junior residents. So this is your time to shine.

Although young anesthesiology studs, you will constantly be presented with "What would you do?" scenarios in residency, they are all for a purpose. The scenarios are usually based on real life experiences by the presenter, and sure enough you will most likely encounter one of these scenarios, and the hope is that you would have gone over it in your head previously.

I am about to finish my 24 hr call, and this "scenario" just happened to me a few hours ago...

Called for urgent intubation in ICU. Upon arrival pt is thin, dyspneic, SpO2 85%, Respiratory therapy is mask ventilating patient with Ambu bag and 100% O2. Pt breathing approximately 40-45 bpm. Pt has history of neutropenia and PE's and RUE vein thrombosis. Pt is alert and understands you but can't communicate verbally due to dyspnea. Pt remains spontaneously breathing at rate of 45 and RT's are doing a good job of mask ventilating and currently holding SpO2 at 85%.

Above was assessed in 30 seconds.

Nurse asks you a question regarding pt's L subclavian central line, the pt's ONLY IV access. She asks is there a reason why the TPN the pt is receiving would be leaking all around the site. The line is hubbed so it is not pulled back too far. You feel the site, and there is obvious crepitus. The central line is not aspirating blood from any port. Every extremity is swollen like the Michelin man, and the nurses state no one has been able to get a PIV.

Above was assessed in 1 minute.

Pt is tiring, still somewhat alert, SpO2 80%.

This is where the ORAL BOARD EXAMINER says,

"How would you intubate this patient, doctor?"

--Again, scenario is geared more toward med students and interns/junior residents

 

[cincincyreds]

This scenario is geared more toward the med students and interns/junior residents. So this is your time to shine.

Although young anesthesiology studs, you will constantly be presented with "What would you do?" scenarios in residency, they are all for a purpose. The scenarios are usually based on real life experiences by the presenter, and sure enough you will most likely encounter one of these scenarios, and the hope is that you would have gone over it in your head previously.

I am about to finish my 24 hr call, and this "scenario" just happened to me a few hours ago...

Called for urgent intubation in ICU. Upon arrival pt is thin, dyspneic, SpO2 85%, Respiratory therapy is mask ventilating patient with Ambu bag and 100% O2. Pt breathing approximately 40-45 bpm. Pt has history of neutropenia and PE's and RUE vein thrombosis. Pt is alert and understands you but can't communicate verbally due to dyspnea. Pt remains spontaneously breathing at rate of 45 and RT's are doing a good job of mask ventilating and currently holding SpO2 at 85%.

Above was assessed in 30 seconds.

Nurse asks you a question regarding pt's L subclavian central line, the pt's ONLY IV access. She asks is there a reason why the TPN the pt is receiving would be leaking all around the site. The line is hubbed so it is not pulled back too far. You feel the site, and there is obvious crepitus. The central line is not aspirating blood from any port. Every extremity is swollen like the Michelin man, and the nurses state no one has been able to get a PIV.

Above was assessed in 1 minute.

Pt is tiring, still somewhat alert, SpO2 80%.

This is where the ORAL BOARD EXAMINER says,

"How would you intubate this patient, doctor?"

--Again, scenario is geared more toward med students and interns/junior residents

Why didn't you just call the cRNA with their doctorate of nursing degree[noctor] to figure this one out.

 

[caligas]

Sometimes you are handed a **** sandwich and none of the options are very good. Really its pretty simple. You can;

1) use the line. Bad idea.
2) give IM sedation (not as bad but still pretty bad).
3) get the tube in awake (reasonable if it works).
4) get access, probably femoral (best option as long as ventilation and oxygenation remains adequate).

 

[excalibur]

Sometimes you are handed a **** sandwich and none of the options are very good. Really its pretty simple. You can;

1) use the line. Bad idea.
2) give IM sedation (not as bad but still pretty bad).
3) get the tube in awake (reasonable if it works).
4) get access, probably femoral (best option as long as ventilation and oxygenation remains adequate).

ORAL BOARD EXAMINER's reply to caligas:

"What would YOU do?" and stares directly at you

 

[michigangirl]

Sometimes you are handed a **** sandwich and none of the options are very good. Really its pretty simple. You can;

1) use the line. Bad idea.
2) give IM sedation (not as bad but still pretty bad).
3) get the tube in awake (reasonable if it works).
4) get access, probably femoral (best option as long as ventilation and oxygenation remains adequate).

If your ventilation and oxygenation is not adequate, or the guy starts to acutely decompensate (about to arrest), which let's be honest, sounds like a reasonable probability, another option is to throw in a proximal humerus or tibial IO. Sounds "mean" and painful but it works. As long as someone is delegated to making sure the thing stays in for the duration of your induction, whatever that is, you have reliable access that gets central fast. You can push anything and everything (i.e. epi), give fluid, etc. Most folks early in their training don't have this on their algorithm of things to do for adults. We use them often in peds, and our program recently started a curriculum which I teach to train all anesthesia residents so that they can have another option at adult codes if needed (EZ-IO on every arrest cart) when access has been attempted and unsuccessful. Lots of practice with chicken legs. EZ-IOs are awesome if you have them, otherwise, a manual I/O with bone marrow aspiration needle works just as well. Just food for thought.

 

[excalibur]

Why didn't you just call the cRNA with their doctorate of nursing degree[noctor] to figure this one out.

This is hilarious, btw!

 

[caligas]

If your ventilation and oxygenation is not adequate, or the guy starts to acutely decompensate (about to arrest), which let's be honest, sounds like a reasonable probability, another option is to throw in a proximal humerus or tibial IO. Sounds "mean" and painful but it works. As long as someone is delegated to making sure the thing stays in for the duration of your induction, whatever that is, you have reliable access that gets central fast. You can push anything and everything (i.e. epi), give fluid, etc. Most folks early in their training don't have this on their algorithm of things to do for adults. We use them often in peds, and our program recently started a curriculum which I teach to train all anesthesia residents so that they can have another option at adult codes if needed (EZ-IO on every arrest cart) when access has been attempted and unsuccessful. Lots of practice with chicken legs. EZ-IOs are awesome if you have them, otherwise, a manual I/O with bone marrow aspiration needle works just as well. Just food for thought.

How many of those do you need to do to be proficient? Whats the learning curve?

In the scenerio described I would get a femoral central line. If pt desaturated in the meanwhile I would intubate.

 

[Dwindlin]

If your ventilation and oxygenation is not adequate, or the guy starts to acutely decompensate (about to arrest), which let's be honest, sounds like a reasonable probability, another option is to throw in a proximal humerus or tibial IO. Sounds "mean" and painful but it works. As long as someone is delegated to making sure the thing stays in for the duration of your induction, whatever that is, you have reliable access that gets central fast. You can push anything and everything (i.e. epi), give fluid, etc. Most folks early in their training don't have this on their algorithm of things to do for adults. We use them often in peds, and our program recently started a curriculum which I teach to train all anesthesia residents so that they can have another option at adult codes if needed (EZ-IO on every arrest cart) when access has been attempted and unsuccessful. Lots of practice with chicken legs. EZ-IOs are awesome if you have them, otherwise, a manual I/O with bone marrow aspiration needle works just as well. Just food for thought.

Aww. You scooped me. EZ-IO has become common place in the pre-hospital environment so it's an option I am comfortable with. In this scenario I would absolutely toss in an IO, proceed with securing airway, would probably go with etomidate/sux (no other vitals given), then worry about finding another access site after airway is secured. As michigangirl said, in the interim the IO can serve as your resuscitation line.

 

[Dwindlin]

How many of those do you need to do to be proficient? Whats the learning curve?

In the scenerio described I would get a femoral central line. If pt desaturated in the meanwhile I would intubate.

Not hard. Tibial is extremely easy, humeral I think is a little more difficult simply because the landmarks (especially in the obese) aren't nearly as clear.

 

[excalibur]

How many of those do you need to do to be proficient? Whats the learning curve?

In the scenerio described I would get a femoral central line. If pt desaturated in the meanwhile I would intubate.

ORAL BAORD EXAMINER's reply to caligas:

"You fail to get femoral central venous access. The pt's condition remains unchanged. She is somewhat alert, RR 45, mask ventilated, SpO2 85%. How would you intubate this patient?"

 

[excalibur]

If your ventilation and oxygenation is not adequate, or the guy starts to acutely decompensate (about to arrest), which let's be honest, sounds like a reasonable probability, another option is to throw in a proximal humerus or tibial IO. Sounds "mean" and painful but it works. As long as someone is delegated to making sure the thing stays in for the duration of your induction, whatever that is, you have reliable access that gets central fast. You can push anything and everything (i.e. epi), give fluid, etc. Most folks early in their training don't have this on their algorithm of things to do for adults. We use them often in peds, and our program recently started a curriculum which I teach to train all anesthesia residents so that they can have another option at adult codes if needed (EZ-IO on every arrest cart) when access has been attempted and unsuccessful. Lots of practice with chicken legs. EZ-IOs are awesome if you have them, otherwise, a manual I/O with bone marrow aspiration needle works just as well. Just food for thought.

WOW! WOW! WOW!

What a great answer! But come on you got to leave some fun for the med students and jr residents.

ORAL BOARD EXAMINER's reply:

"This facility does not have instruments to establish IO access"

--BTW, my hospital's ICU does not, so examiner not being an ass, it is always a possibility

 

[PonyUp]

I might kill the patient but I'll bite.

Call for help - you might *be* the help but I can't intubate and put in a chest tube at the same time.

Auscultate the patient to evaluate for pneumothorax. Look for tracheal deviation. Assume the subcutaneous emphysema and new desaturation is 2/2 to pneumothorax until proven otherwise. Can confirm with needle thoracostomy which would also act as a temporizing measure. If no pneumothorax, all the better. Clinical picture fits PE as well given hx.

As far as access for induction, I am most comfortable with an awake right IJ if all peripheral access is not an option as it appears to be based on your description. I feel like most other people might feel a femoral is indicated but I honestly am better at hitting the IJ because I've had the most practice, and also puts me at HOB. Might have a distorted anatomy if the guy has a pneumothorax. If IO is an option you can have someone else in the room do that while you prepare to intubate.

Once IJ or IO is in place, prop sux tube.

 

[PonyUp]

Was hesitant to go RIJ incase clot has extended, but left sided IJ seems more risky to me given loss of access on that side.

 

[excalibur]

I might kill the patient but I'll bite.

Call for help - you might *be* the help but I can't intubate and put in a chest tube at the same time.

Auscultate the patient to evaluate for pneumothorax. Look for tracheal deviation. Assume the subcutaneous emphysema and new desaturation is 2/2 to pneumothorax until proven otherwise. Can confirm with needle thoracostomy which would also act as a temporizing measure. If no pneumothorax, all the better. Clinical picture fits PE as well given hx.

As far as access for induction, I am most comfortable with an awake right IJ if all peripheral access is not an option as it appears to be based on your description. I feel like most other people might feel a femoral is indicated but I honestly am better at hitting the IJ because I've had the most practice, and also puts me at HOB. Might have a distorted anatomy if the guy has a pneumothorax. If IO is an option you can have someone else in the room do that while you prepare to intubate.

Once IJ or IO is in place, prop sux tube.

Excalibur's reply: "Most impressive"

ORAL BOARD EXAMINER's reply:

"You auscultate both lungs and hear clear EBBS. Trachea is midline. You successfully place your RIJ central line. You induce pt as described, but you are unable to intubate. What would you do?"

 

[excalibur]

Haha. I have got to get some sleep as I am postcall.

SDN attendings feel free to continue on this scenario as the ORAL BOARD EXAMINER and teach our young anesthesiology studs

 

[PonyUp]

Excalibur's reply: "Most impressive"

ORAL BOARD EXAMINER's reply:

"You auscultate both lungs and hear clear EBBS. Trachea is midline. You successfully place your RIJ central line. You induce pt as described, but you are unable to intubate. What would you do?"

Can't intubate, can't ventilate. Call for a crich/trach kit, and overhead page for an ENT or Surgeon while I place an LMA. Hopefully the LMA will work.

I don't suppose the oral board examiner tells you why you couldn't intubate?

 

[jwk]

Can't intubate, can't ventilate. Call for a crich/trach kit, and overhead page for an ENT or Surgeon while I place an LMA. Hopefully the LMA will work.

I don't suppose the oral board examiner tells you why you couldn't intubate?

Ah, remember - can't intubate and can't ventilate are two different things. One condition does not necessarily imply the other.

 

[PonyUp]

Ah, remember - can't intubate and can't ventilate are two different things. One condition does not necessarily imply the other.

I thought we had demonstrated that he was desatting while being bagged at 100%.

The reason I asked in my prior post why intubation failed is that I'd want to push more sux/propofol/positive pressure if I could see that his cords were closed. It is my understanding that if we're gaming the oral boards, questions like that are more likely to get you into trouble than just answering a question.

Fairly sure I might be working with you in the future IIRC 😉

 

[michigangirl]

WOW! WOW! WOW!

What a great answer! But come on you got to leave some fun for the med students and jr residents.

sorry ;-) I thought about not saying anything but it seemed like too good a teaching opportunity not to bring up my love of I/Os. 😍

 

[imfrankie]

Don't let the blind nasal become a lost art.

 

[excalibur]

Can't intubate, can't ventilate. Call for a crich/trach kit, and overhead page for an ENT or Surgeon while I place an LMA. Hopefully the LMA will work.

I don't suppose the oral board examiner tells you why you couldn't intubate?

Ok. Excalibur's comments. The examiner may or may not tell you why you couldn't intubate. He may say "Grade 4 laryngoscopic view and can't intubate" or he may just say "can't intubate". The likeliest scenario is that you simply couldn't see glottis. In the ORAL BOARD game this is called "ambiguity". You are presented with a problem, but important info that you would like to know may have not been presented. You don't ask questions back to examiners to resolve ambiguity. You resolve ambiguity by answering the initial question with "IF--THEN" statements. IF I could not intubate because of an anterior view OR the glottis appeared deep, AND the pt's oxygenation level had not decreased, THEN I would quickly change to a straight blade or longer blade in an attempt to improve my view. HOWEVER, if the reason I couldn't intubate was because the cords were shut, I would CONSIDER giving more succinylcholine.

You see how much ambiguity was answered with that statement and you answered the initial question. You also see the conditional words thrown in there? "AND"--I would only dick around for a second attempt at intubation if pt's oxygenation status was same as pre-induction. If decreasing, ventilation would take priority in my judgment and I would attempt mask ventilation with oral airway. --Remember, ventilation may be easier and oxygenation may improve from pre-induction once pt is unconscious and paralyzed.

If you read jwk's response, you might suspect he feels you went too early for surgical airway, and in truth, I do too. BUT, I am me, he is him, and you are you. So you may have a reasonable explanation on why you "called for ENT for surgical airway, while you attempted to place LMA". So ORAL BOARD EXAMINER may want to hear your reasoning. --I know you have had failed intubation attempts in the OR, and you don't page ENT for help, so he wants to hear why you are doing it here. Your response could very well be justified, but we have to hear your reasoning.

ORAL BOARD EXAMINER's reply:

"You would call ENT for a surgical airway after one failed intubation on this patient?"

 

[soonerfrog]

Great case discussion. However, no one else wanted to point out that Excalibur had 2 ****ty cases in one week...one of which was post-call on his way out the door! Welcome to private practice folks. It's still got Academia beat but clearly, it ain't all peaches and cream 24/7. Great learning cases though.

 

[PonyUp]

Ok. Excalibur's comments. The examiner may or may not tell you why you couldn't intubate. He may say "Grade 4 laryngoscopic view and can't intubate" or he may just say "can't intubate". The likeliest scenario is that you simply couldn't see glottis. In the ORAL BOARD game this is called "ambiguity". You are presented with a problem, but important info that you would like to know may have not been presented. You don't ask questions back to examiners to resolve ambiguity. You resolve ambiguity by answering the initial question with "IF--THEN" statements. IF I could not intubate because of an anterior view OR the glottis appeared deep, AND the pt's oxygenation level had not decreased, THEN I would quickly change to a straight blade or longer blade in an attempt to improve my view. HOWEVER, if the reason I couldn't intubate was because the cords were shut, I would CONSIDER giving more succinylcholine.

You see how much ambiguity was answered with that statement and you answered the initial question. You also see the conditional words thrown in there? "AND"--I would only dick around for a second attempt at intubation if pt's oxygenation status was same as pre-induction. If decreasing, ventilation would take priority in my judgment and I would attempt mask ventilation with oral airway. --Remember, ventilation may be easier and oxygenation may improve from pre-induction once pt is unconscious and paralyzed.

If you read jwk's response, you might suspect he feels you went too early for surgical airway, and in truth, I do too. BUT, I am me, he is him, and you are you. So you may have a reasonable explanation on why you "called for ENT for surgical airway, while you attempted to place LMA". So ORAL BOARD EXAMINER may want to hear your reasoning. --I know you have had failed intubation attempts in the OR, and you don't page ENT for help, so he wants to hear why you are doing it here. Your response could very well be justified, but we have to hear your reasoning.

ORAL BOARD EXAMINER's reply:

"You would call ENT for a surgical airway after one failed intubation on this patient?"

All good points.

I would likely answer the question with:

"I would call ENT because at that point I have time to call ENT before having to cut the patient myself. I am at the branch point of the airway algorithm where a surgical airway is the next option if I were to fail. My impression given the information was that this patient was satting 80% being bag-masked at 100% fiO2."

Essentially, you've got a patient with a dropping O2 sat [that reflects his saturation 30 seconds ago], who is paralyzed and not breathing on his own. If we gave prop and sux for the RSI we've already given 2 of the 3 treatments that I know of for a laryngospasm [as a lowly CA(-1)]. You are right to point out we should give positive pressure and try and ventilate with a mask after failing to intubate him in case he loosened up...but I also would ask someone else in the room to have an LMA handy.

I guess calling the ENT was just me thinking ahead down the algorithm. That and I didnt feel like performing my first crich on a human.

 

[Ignatius J]

Just curious, in this scenario if the patient really starts to crump and you can't get access, anyone who would IM sux the patient, tube, then throw resuscitative meds down the ETT? I think I would consider.

If he continues to sat in the '80s, I would try another central vein cannulation/IO then proceed with intubation. But if he really started crumping and couldn't maintain his airway at all, I'm securing the airway and not hesitating to resuscitate through the ETT while I quickly try and establish IV access after.

Also, would consider needle decompression initially if I had a high index of suspicion for a pneumo. Benefit definitely outweighs the risk (unintended invasive procedure) if I had a high index of suspicion.

 

[excalibur]

All good points.

I would likely answer the question with:

"I would call ENT because at that point I have time to call ENT before having to cut the patient myself. I am at the branch point of the airway algorithm where a surgical airway is the next option if I were to fail. My impression given the information was that this patient was satting 80% being bag-masked at 100% fiO2."

.

ORAL BOARD EXAMINER's reply:

"OK. Let's say you hold off on calling ENT for now, and after your failed intubation, you mask ventilate the patient. Ventilation is easy and SpO2 increases to 97%. How would you proceed with trying to intubate this patient now?"

 

[excalibur]

If he continues to sat in the '80s, I would try another central vein cannulation/IO then proceed with intubation. But if he really started crumping and couldn't maintain his airway at all, I'm securing the airway and not hesitating to resuscitate through the ETT while I quickly try and establish IV access after.
.

ORAL BOARD EXAMINER's reply:

"You auscultate the lungs and hear EBBS. Pt maintains sats in the 80's with assisted mask ventilation. You quickly place a central line and perform a RSI. Upon direct laryngoscopy the patient vomits copious gastric contents ino the oropharynx. How would you proceed?"

 

[PonyUp]

ORAL BOARD EXAMINER's reply:

"OK. Let's say you hold off on calling ENT for now, and after your failed intubation, you mask ventilate the patient. Ventilation is easy and SpO2 increases to 97%. How would you proceed with trying to intubate this patient now?"

The patient is now stable [for the time being] with mask ventilation which opens up some more time-intensive options.

If the cords were too anterior to visualize with the initial laryngoscope, I would opt to use a c-mac or glidescope if one was available [or, as you mentioned earlier, just a different blade]. If the cords were not visible 2/2 to obstruction, I would likely attempt to find some tracheal rings with my bougie.

If secretions or [blood from his newly macerated vallecula 😛 ] were the problem before, I'd have a suction in hand this time.

If the cords were closed previously, I'd do a repeat DL and attempt with the same size 7.0 or 8.0 tube if I got a good view with now-open cords. If the tube I had selected before wouldn't pass but I had good visualization, I would re-attempt with a smaller tube.

There are plenty of airway toys that could also help in this case, if direct laryngoscopy fails with the above approaches exhausted - depends whether you've got intubating LMAs or disposable fiber-optic combos like the aura-I +ascope2 at your hospital.

Fiber optic is another option.

 

[Ignatius J]

Suction, suction, more suction. Then continue on with securing the airway. Continue to monitor oxygen saturations and signs of pulmonary aspiration. If I was concerned for aspiration clinically, I would order a chest x- ray and look for signs of pulmonary aspirate such as infiltrates in the right lower lobe.

 

[excalibur]

The patient is now stable [for the time being] with mask ventilation which opens up some more time-intensive options.

If the cords were too anterior to visualize with the initial laryngoscope, I would opt to use a c-mac or glidescope if one was available [or, as you mentioned earlier, just a different blade]. If the cords were not visible 2/2 to obstruction, I would likely attempt to find some tracheal rings with my bougie.

If secretions or [blood from his newly macerated vallecula 😛 ] were the problem before, I'd have a suction in hand this time.

If the cords were closed previously, I'd do a repeat DL and attempt with the same size 7.0 or 8.0 tube if I got a good view with now-open cords. If the tube I had selected before wouldn't pass but I had good visualization, I would re-attempt with a smaller tube.

There are plenty of airway toys that could also help in this case, if direct laryngoscopy fails with the above approaches exhausted - depends whether you've got intubating LMAs or disposable fiber-optic combos like the aura-I +ascope2 at your hospital.

Fiber optic is another option.

ORAL BOARD EXAMINER's reply:

"On your second DL you visualize cords and intubate. You confirm endotracheal placement with ETCO2 color change. You notice that ventilation is decreased due to decreased compliance of the bag. What is your differential?"

 

[excalibur]

Suction, suction, more suction. Then continue on with securing the airway. Continue to monitor oxygen saturations and signs of pulmonary aspiration. If I was concerned for aspiration clinically, I would order a chest x- ray and look for signs of pulmonary aspirate such as infiltrates in the right lower lobe.

ORAL BOARD EXAMINER's reply:

"On your second DL you visualize cords and intubate. You confirm endotracheal placement with ETCO2 color change. You notice that ventilation is difficult due to decreased compliance of the bag. What is your differential?"

 

[IlDestriero]

How many of those do you need to do to be proficient? Whats the learning curve?

In the scenerio described I would get a femoral central line. If pt desaturated in the meanwhile I would intubate.

One = proficiency. (For tibial)
Go to a class at a meeting and you're good to go.
Next time the above presents itself, trauma, etc. Just do it.

 

[ssmallz]

ORAL BOARD EXAMINER's reply:

"On your second DL you visualize cords and intubate. You confirm endotracheal placement with ETCO2 color change. You notice that ventilation is decreased due to decreased compliance of the bag. What is your differential?"

This is a DDx that every oral board examinee should know cold and be able to spit out in less than 30 seconds. You WILL have to do this one of your oral board scenerios almost guaranteed

 

[PonyUp]

ORAL BOARD EXAMINER's reply:

"On your second DL you visualize cords and intubate. You confirm endotracheal placement with ETCO2 color change. You notice that ventilation is decreased due to decreased compliance of the bag. What is your differential?"

Apologies - fiancee's bday dinner straight from clinic yesterday and zonked out as soon as I got home.

High airway pressure:

Tube is right mainstem
Mucus plug or other obstruction
Hypoxic vasoconstriction
Tension pneumothorax
ARDS
Bronchospasm
Goosed intubation [we had color change but you never know]
Probably a whole slue of others applicable to the surgical setting but I'd rather not cheat.

At this point, I would likely check breath sounds to rule out a deep tube, pneumothorax, or localize an obstruction. If those were ruled out I would take the circuit out of the equation and hook up the ambu bag again to see what he feels like to bag. From there I'd check the tube itself, pass a suction cath, etc.

 

[PonyUp]

Just saw NKDA on a chart and remembered anaphylaxis - add that to my differential

 

[DocVapor]

I just want to say thank you to everyone who posts these scenarios. I am just an MS 1, but I love reading them and realizing how much more I need to learn. This one in particular was great for me because I could keep up for a while thanks to my EMS background.

So,
👍

Sent from my DROID RAZR HD using SDN Mobile

 

[Gern Blansten]

+1 for the blind nasal. Might stir up some bleeding, but can sometimes really get you out of a jam.

 

[excalibur]

Apologies - fiancee's bday dinner straight from clinic yesterday and zonked out as soon as I got home.

High airway pressure:

Tube is right mainstem
Mucus plug or other obstruction
Hypoxic vasoconstriction
Tension pneumothorax
ARDS
Bronchospasm
Goosed intubation [we had color change but you never know]
Probably a whole slue of others applicable to the surgical setting but I'd rather not cheat.

At this point, I would likely check breath sounds to rule out a deep tube, pneumothorax, or localize an obstruction. If those were ruled out I would take the circuit out of the equation and hook up the ambu bag again to see what he feels like to bag. From there I'd check the tube itself, pass a suction cath, etc.

In the background you hear "Knock, Knock, Knock"

ORAL BOARD EXAMINER's reply:

Thank you. That's all the time we have.

--------------------------------------------------------------------------------------------------

-As you can see there are different methods, and the more you know, the more options you have.

IO access
blind nasal
IM sux

All things that anesthesiologists should keep in mind.

Our ICU does not have IO access capability. Or at least I don't think they do. I am not skilled in blind nasal, but I know the procedure and technique from my asleep nasals. Actually, one should practice blind nasal intubations on asleep nasal intubations for dental surgery. Never thought of that actually. I have never given IM sux but I know when to give it.

In my scenario what I did was since the pt was holding steady, I put in a RIJ central line with RT's assisting under the drapes. I had told the ICU nurse to attach small gauge needle to Sux and I was planning on giving IM sux if things were going bad and explaining to pt that unfortunately she might recall the intubation prior to giving it.

IJ went fine, prop, sux, tube.


--In thinking of stuff for the exercise we had, I was thinking what if I gave IM sux, no IV, and then pt developed trismus and I couldn't open the mouth.

Any takers??

 

[cincincyreds]

In the background you hear "Knock, Knock, Knock"

ORAL BOARD EXAMINER's reply:

Thank you. That's all the time we have.

--------------------------------------------------------------------------------------------------

-As you can see there are different methods, and the more you know, the more options you have.

IO access
blind nasal
IM sux

All things that anesthesiologists should keep in mind.

Our ICU does not have IO access capability. Or at least I don't think they do. I am not skilled in blind nasal, but I know the procedure and technique from my asleep nasals. Actually, one should practice blind nasal intubations on asleep nasal intubations for dental surgery. Never thought of that actually. I have never given IM sux but I know when to give it.

In my scenario what I did was since the pt was holding steady, I put in a RIJ central line with RT's assisting under the drapes. I had told the ICU nurse to attach small gauge needle to Sux and I was planning on giving IM sux if things were going bad and explaining to pt that unfortunately she might recall the intubation prior to giving it.

IJ went fine, prop, sux, tube.


--In thinking of stuff for the exercise we had, I was thinking what if I gave IM sux, no IV, and then pt developed trismus and I couldn't open the mouth.

Any takers??

Wow, trismus after Sux? Hope you don't got MH also on top of no IV access and respiratory failure. I guess you could try IM ROC to break the trismus, maybe the patient is missing a tooth and you can stick some ROC under the patient's tongue as that area is pretty vascular.

 

[bkell101]

Blind nasal?

 

[bkell101]

I just want to say thank you to everyone who posts these scenarios. I am just an MS 1, but I love reading them and realizing how much more I need to learn. This one in particular was great for me because I could keep up for a while thanks to my EMS background.

So,
👍

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I second this...can the moderators just post a daily case? Even if its simple and short ...I'd much rather read along with interaction than stare at my basic miller on the iPad

 

[pgg]

Blind nasal?

Just what it sounds like ... tube is stuck in the nose blindly. With the way the oropharynx is shaped, you actually have a good chance of putting it through the cords.

There exist some special tubes and tools that make it a little easier, but basically you just stick it in there and give it a shove during inspiration, and hopefully it winds up in the trachea. Doesn't work in apneic patients.

 

[bkell101]

Just what it sounds like ... tube is stuck in the nose blindly. With the way the oropharynx is shaped, you actually have a good chance of putting it through the cords.

There exist some special tubes and tools that make it a little easier, but basically you just stick it in there and give it a shove during inspiration, and hopefully it winds up in the trachea. Doesn't work in apneic patients.

Oh sorry I guess I should have clarified....blind nasal was my answer for the patient in trismus after Im sux and no iv access......never done one, but I've seen people come in by squad like this

 

[Planktonmd]

Blind nasal?

Blind nasal is great but in the hands of someone who has done them before!
Unfortunately not many youngsters have done or even seen a blind nasal intubation.
So, if you get to a point that your best or only choice is a blind nasal intubation and you have never done or seen one then please... don't try that!
Place an LMA or just mask ventilate and call someone more experienced than you to come help you.

 

[DocVapor]

Quick question:

Are King Airways getting used much in the OR setting? It seems like they are getting favored more and more in the EMS world around me but I am not entirely convinced by them yet.

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[Arch Guillotti]

Quick question:

Are King Airways getting used much in the OR setting? It seems like they are getting favored more and more in the EMS world around me but I am not entirely convinced by them yet.

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The only time we see King Airways are when we switch them out for an ET tube.

 

[Bostonredsox]

The only time we see King Airways are when we switch them out for an ET tube.

/nod. King airways are not definitive airways. The first thing I do when EMS brings in a code blue with one is swap it for an ETT to make sure they are actually getting air to 'dose 'dem 'alveeelii.

 

[fakin' the funk]

Are King Airways getting used much in the OR setting? It seems like they are getting favored more and more in the EMS world around me but I am not entirely convinced by them yet.

Thing of the King like a Combitube.

It's a rescue device, or a device for non-experts to shove in the mouth and hopefully get a decent result.

So no, we don't have these in the OR. One of our airway guys is trying to figure out a way to use it as an intubation conduit though, given the increased frequency that the EMS people are using them.

 

[soxman]

what about retrograde intubation? Is that even done anymore? I would think that would be quicker and you could still pass that guide wire even if the whole oral cavity is filled with vomit

 

[aredoubleyou]

Ketamine + lidocaine + glidescope. If the ketamine goes into mediastinum, then just lido + glide. Check your platelets on neutropenic patients before playing with this blind nasal stuff.

 

[deleted59964]

ketamine goes sublingual, sux IM into tongue