Impending Airway Disasters

[UnderwaterDoc]

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So during my last block of overnights I had two cases in the wee hours of the morning that severely tested my sphincter tone, and I was wondering what is the opinion of the community docs in regards to dispo.

Case 1 - 50s female, on ACEIs, walks in with a neck the size of a basketball, "it started 2 days ago doctor", protruding tongue, her breathing sounds like one of the zombies from the walking dead, dysphonic, zero neck landmarks...you get the picture, angioedema of doom.

Case 2 - 40s male, no PMHx, recently diagnosed with "throat cancer", in the process of being staged blah blah. Brought in by EMS because of two days of difficulty breathing. I could hear him stridor-ing from across our very long ED, when I look at him he is tripoding, sniffing position, looks like will get tired of all this work of breathing soon and will crump at any minute, no bueno.

For both of these I called ENT and anesthesia before I even walked in the room. We managed with steroids, H2 blockers, non rebreathers, prayers, and in the case of the cancer guy, vapo vapo vapo. Both of these were scoped in the ED after we had every airway adjunct available at bedside, and neither had an intubatable airway (not even with fiberoptics!!). Both went to the OR emergently for traches.

So my question is, what the hell do you do with these out in the community with no ENT or anesthesia on call? The obvious answer is transfer, but I would be terrified to send these people on an ambulance ride without securing their airways first, and both of these ended up being surgical airways so having fiberoptics available would not have done squat. I was thinking that I could call in whoever is on-call for my group (yes they have that here) to cover my ED temporarily while I ride in the ambulance to the accepting facility, scalpel in hand and surgical airway at the ready. Thoughts?

 

[RustedFox]

I had a bad angioedema last night. ACE-I on the drug list. Gal was just getting worse despite SoluMedrol, H1&2 blockers and fluids. Hit her with epi, which did nothing but make the 92 year-old gal agitated. I called anesth in for awake fiberoptic nasotracheal (she was totally still controlling airway and secretions, but could 'tip over' at any hot second). Meanwhile, I hit her with 500 mg SoluMedrol in 1L NS and got respiratory, glidescope, and trach kit to bedside. By the time anesth. got to the ER (20-30 mins), she went from "OMGairwayMESS" to infinitely better. So much better, in fact that I looked like a ******* once anesth got there. Fortunately, respiratory (old man with lots of grey) piped up and said - "This is a different girl than I saw 20 minutes ago, Anesthesia. That extra solumedrol must'a done the trick."

Anesthesia was cool about it. Much more - "Hey, man - it's the right thing for the patient that counts." and not "Your (sic) a dumass LOLZ."

Other thoughts on non-ETT management include:

FFP. Has angiotensin-converting enzyme IN it, so will help with ACE-I assoc. angioedema. I had 2 liters being thawed STAT by the time I made the decision to pursue more aggressive management.

For hereditary angioedema (HANE) cases, there are specific drugs like Kalbitor (and others). At my shop, we actually have a late 20-something gal who has HANE, and comes to the ER with her own box of Kalbitor and instructions on how to use and what to look out for. Her HANE isn't oral/mucocutaneous, its largely GI-and-skin. She gets a weirdo rash and complains of abd. pain that you and I would call "bogus" after physical exam in a heartbeat. Hit her with the kalbitor and she praises the ground that you walk on in 10-15 mins.

 

[Bostonredsox]

So during my last block of overnights I had two cases in the wee hours of the morning that severely tested my sphincter tone, and I was wondering what is the opinion of the community docs in regards to dispo.

Case 1 - 50s female, on ACEIs, walks in with a neck the size of a basketball, "it started 2 days ago doctor", protruding tongue, her breathing sounds like one of the zombies from the walking dead, dysphonic, zero neck landmarks...you get the picture, angioedema of doom.

Case 2 - 40s male, no PMHx, recently diagnosed with "throat cancer", in the process of being staged blah blah. Brought in by EMS because of two days of difficulty breathing. I could hear him stridor-ing from across our very long ED, when I look at him he is tripoding, sniffing position, looks like will get tired of all this work of breathing soon and will crump at any minute, no bueno.

For both of these I called ENT and anesthesia before I even walked in the room. We managed with steroids, H2 blockers, non rebreathers, prayers, and in the case of the cancer guy, vapo vapo vapo. Both of these were scoped in the ED after we had every airway adjunct available at bedside, and neither had an intubatable airway (not even with fiberoptics!!). Both went to the OR emergently for traches.

So my question is, what the hell do you do with these out in the community with no ENT or anesthesia on call? The obvious answer is transfer, but I would be terrified to send these people on an ambulance ride without securing their airways first, and both of these ended up being surgical airways so having fiberoptics available would not have done squat. I was thinking that I could call in whoever is on-call for my group (yes they have that here) to cover my ED temporarily while I ride in the ambulance to the accepting facility, scalpel in hand and surgical airway at the ready. Thoughts?

If i truly though they were in danger of losing their airway and i took a peak with a glidescope and saw tumor occluding everything, I would cric them and then ship them. If if was daytime I would Cric them to secure the airway, then call one of the gen surgeons to convert my cric to a bedside trach.

 

[blue2000]

Don't usually frequent this forum, but general surgeons should be able to trach people like this, even out in the community. I have done the trach on your second case.

 

[dchristismi]

In my community shop, we have anesthesia generally 15 minutes away, and all of our gen surgeons can do a slash trach. We have glidescope, LMAs (which are really handy), bougies, fiberoptics (if you know how to use it) and intubating LMAs on our cart. And the cric kit.

Any community shop will have a protocol/plan in place for this situation because it does happen - you just don't want it to become a cannot-intubate/cannot-ventillate situation. You should be able to cric in a pinch, but my anesthesia guys are pretty quick to respond, and more than once (ok, so I've only called for help a couple of times), they ask for the gen surgeon to be paged stat, and announce that they're going to the OR. I have no ENTs, period, so if it's truly an ENT issue like your neck cancer guy, they get transferred AFTER you secure the airway.

 

[southerndoc]

Cric or don't forget a great tool: retrograde intubation. It's worked well twice for me (one for angioedema, another for a bloody airway while a paramedic).

 

[Apollyon]

Cric or don't forget a great tool: retrograde intubation. It's worked well twice for me (one for angioedema, another for a bloody airway while a paramedic).

You HAD a wire on the ambulance, to pass for the retrograde? Was it for this once-in-a-blue-moon/die-from-falling-out-of-bed-while-being-mauled-by-a-bear-struck-by-lightning moment?

 

[Daiphon]

Cric or don't forget a great tool: retrograde intubation. It's worked well twice for me (one for angioedema, another for a bloody airway while a paramedic).

One of my favorite tricks, actually. Residents, nurses, and even some attendings* go ****oo for cocoa puffs when you bust this out. d=)

*2x: anesthesia light source on the fiberoptic fail, and 600# neck that crumped before the nurse could grab me a scalpel - just appropriated the TLC kit I already had open for the post-cric IJ

Sent from my DROID BIONIC using Tapatalk

 

[Tiger26]

Good cases and the most challenging we see. My approach is to start mobilizing every option in parallel the moment I see them.

1) Anesthesia or ENT consult
2) Steroids, epi, H1/H2 blockers
3) Nebulize 4% lido and do topical nasal and oral lido through an atomizer
4) Set up for fiberoptics equipment (have experience after spending some time in the bronchoscopy suite on elective to get some more experience after doing a few of these in the ED)

*For the residents, the most important advice I got on this was to scope every sore throat you see so that you know the anatomy, normal/not normal, and have the muscle memory to do it for real with an ET tube over a bronchoscope

5) Have cric kit ready (for me, a 6.0 ETT, hemostat, scalpel, and bougie) with cricothyroid membrane location marked with a sharpie
6) Glycopyrlate or Atropine for secretions
7) Versed or Ketamine at low-ish dose
8) Likely fiberoptic (nasal or oral depending on swelling)

 

[thorg12]

What wire do you guys use for retrograde intubation? Is the wire from 20cm TLC long enough and stiff enough? I feel like the ones we practiced with in pig lab are thicker ir wires.

 

[southerndoc]

You HAD a wire on the ambulance, to pass for the retrograde? Was it for this once-in-a-blue-moon/die-from-falling-out-of-bed-while-being-mauled-by-a-bear-struck-by-lightning moment?

Helicopter

 

[Cynic]

helicopter

ftw.

 

[Arcan57]

Helicopter

160 mph and an airway...

 

[docB]

Cric or don't forget a great tool: retrograde intubation. It's worked well twice for me (one for angioedema, another for a bloody airway while a paramedic).

What wire do you guys use for retrograde intubation? Is the wire from 20cm TLC long enough and stiff enough? I feel like the ones we practiced with in pig lab are thicker ir wires.

I agree with the retrograde. I've done it about 8 times with a really good success rate. Another advantage of it is that when you're done you have an ETT. You don't have to call anyone to convert it or otherwise deal with the aftermath.

You can use a central line in a pinch. If you have a kit for a dialysis cath it's better. The best is the actual retrograde kit (by Arrow I think). It's got a long thick wire and a longer thicker obturator that really helps to avoid kinking over at the puncture site. I highly recommend it.

 

[dchristismi]

Ah, the dialysis kit wire...

I have only tried 2 retrogrades, and couldn't get either. (But was using central line wire...) I love the idea, though, and do keep it in the back of my mind. Will have to try it again sometime.

 

[e30ftw]

Just curious regarding the indications for retrograde intubation.

Seems like it'd be used for those times when you need the difficult airway but not emergently enough to cric. However for the completely obstructed, edematous necked angioedema or ludwigs patient, would the edematous changes in oropharygeal anatomy inhibit wire passage? I guess you could convert to a cric by extending the incision at the site of the wire and putting the tube through the cricothyroid membrane.

Would you use this on the fat necked OSA/CHFer w/ anticipated difficult airway if you didn't have access to a bronchoscope?

Personally as an intern I have never seen a retrograde and have only seen a few awake fiberoptic tubes, but those were in the OR. Our most common difficult airway technique in the ED is glidescope + bougie.

 

[Arcan57]

Just curious regarding the indications for retrograde intubation.

Seems like it'd be used for those times when you need the difficult airway but not emergently enough to cric. However for the completely obstructed, edematous necked angioedema or ludwigs patient, would the edematous changes in oropharygeal anatomy inhibit wire passage? I guess you could convert to a cric by extending the incision at the site of the wire and putting the tube through the cricothyroid membrane.

Would you use this on the fat necked OSA/CHFer w/ anticipated difficult airway if you didn't have access to a bronchoscope?

Personally as an intern I have never seen a retrograde and have only seen a few awake fiberoptic tubes, but those were in the OR. Our most common difficult airway technique in the ED is glidescope + bougie.

There are few indications for a retrograde intubation with modern airway equipment. Basically you're banking on an airway that you couldn't visualize from above yet isn't obstructed enough that you can still pass the tube orally. Video laryngoscopy has removed a lot of the "can't visualize" difficult intubations and the bougie has made even poor views a good bet for tube through trachea. In most cases, if you have the above equipment and you're still thinking retrograde intubation then you're probably just desperately trying to avoid doing the crich. Having a guidewire in trach (or even better through crichothyroid) is all sorts of useful if your landmarks are horrible, but at that point you should probably just go ahead and dilate (Quick-Trach) or cut to get the tube in place.

 

[glorfindel]

... We managed with steroids, H2 blockers, non rebreathers, prayers, ....

I had a bad angioedema last night. ACE-I on the drug list. Gal was just getting worse despite SoluMedrol, H1&2 blockers and fluids. Hit her with epi, which did nothing but make the 92 year-old gal agitated. ...

It's interesting that despite all the statements we're constantly reading that epi/steroids/H blockers don't do anything for angioedema, we seem to routinely give them anyway. The case reports always state that "...no improvement was noted after the parenteral administration of diphenhydramine, methylprednisolone, and epinephrine." http://www.nejm.org/doi/full/10.1056/NEJMicm1014034

I can't fault anyone for giving these things, because, well, maybe it's not bradykinin-mediated angioedema. But if I see a swollen tongue/uvula/cords with no other symptoms that suggest anaphylaxis, I'll want my RNs' time spent giving me meds and making phone calls aimed at intubation, not anaphylaxis. After their airway is secured, then sure, give the steroids. The hospitalists all seem to want them, and... maybe I've misdiagnosed the patient?

But probably not.

 

[UnderwaterDoc]

It's interesting that despite all the statements we're constantly reading that epi/steroids/H blockers don't do anything for angioedema, we seem to routinely give them anyway. The case reports always state that "...no improvement was noted after the parenteral administration of diphenhydramine, methylprednisolone, and epinephrine." http://www.nejm.org/doi/full/10.1056/NEJMicm1014034

I can't fault anyone for giving these things, because, well, maybe it's not bradykinin-mediated angioedema. But if I see a swollen tongue/uvula/cords with no other symptoms that suggest anaphylaxis, I'll want my RNs' time spent giving me meds and making phone calls aimed at intubation, not anaphylaxis. After their airway is secured, then sure, give the steroids. The hospitalists all seem to want them, and... maybe I've misdiagnosed the patient?

But probably not.

You know, I was thinking the same thing as we gave them, but since we were not going to attempt intubation/cric without ENT or anesthesia present (unless there was significant clinical decline), its not like our nursing could have been used more effectively. Besides I wanted to do something for the patient besides scaring the crap out of them getting all my airway stuff ready.

I could swear that in the angioedema lady her swelling improved after we gave the meds, although maybe her swelling would have improved anyway? I did not notice any improvement whatsoever in the cancer guy over the time that he was with us.

That was an interesting suggestion about the FFP, I'll have to read about it as I've never seen it done for the cases we've had here, which are few and far between thankfully.

 

[southerndoc]

If it's a bad angioedema, I give FFP. Firazyr and Berinert remain viable options if you have them. Firazyr probably will work better since it directly inhibits bradykinin receptors as opposed to inhibiting bradykinin production.

 

[thorg12]

southerdoc,
isn't that stuff just for hereditary angioedema? Do you just give it in case they could be a hereditary case? I have never given it before. at my residency we see a good amount of bad angioedema; I would say one every 2-3 weeks who is drooling, and is pretty close to losing their airway. Its usually a 50-60 african american on lisinopril.
At our main place we actually have a difficult airway team that comes down and awake nasal intubates them.
At our other sites I have nebulized and atomized lidocaine; mark their neck and numb them up; then I take an awake look with glidescope, with 1mg/kg of ketamine. My n of 3; 2 glidescope and 1 cric and in retrospect I think we should have looked longer and prob could have gotten the tube instead of cric. we don't have anesthesia and some of our other sites.
my ketamine lidocaine combo has been serving me well so far; anyone else tried it?

 

[southerndoc]

southerdoc,
isn't that stuff just for hereditary angioedema? Do you just give it in case they could be a hereditary case? I have never given it before. at my residency we see a good amount of bad angioedema; I would say one every 2-3 weeks who is drooling, and is pretty close to losing their airway. Its usually a 50-60 african american on lisinopril.
At our main place we actually have a difficult airway team that comes down and awake nasal intubates them.
At our other sites I have nebulized and atomized lidocaine; mark their neck and numb them up; then I take an awake look with glidescope, with 1mg/kg of ketamine. My n of 3; 2 glidescope and 1 cric and in retrospect I think we should have looked longer and prob could have gotten the tube instead of cric. we don't have anesthesia and some of our other sites.
my ketamine lidocaine combo has been serving me well so far; anyone else tried it?

The FDA approved them for hereditary angioedema. They will work with ACE-induced AE as well since the problem is from an accumulation of bradykinin (due to ACE inhibition of bradykinase). Firazyr (a bradykinin receptor antagonist) would work the best for this. There have been case reports describing this, but no good research.

 

[docB]

There are few indications for a retrograde intubation with modern airway equipment. Basically you're banking on an airway that you couldn't visualize from above yet isn't obstructed enough that you can still pass the tube orally. Video laryngoscopy has removed a lot of the "can't visualize" difficult intubations and the bougie has made even poor views a good bet for tube through trachea. In most cases, if you have the above equipment and you're still thinking retrograde intubation then you're probably just desperately trying to avoid doing the crich. Having a guidewire in trach (or even better through crichothyroid) is all sorts of useful if your landmarks are horrible, but at that point you should probably just go ahead and dilate (Quick-Trach) or cut to get the tube in place.

I disagree. I have run into the situation of can't intubate but can ventilate enough to buy some time way more often than the stone cold can't intubate, can't ventilate scenario. I cric immediately in that case. The retrograde is great for the situations where you can't see, either direct or with video, and the bougie keeps going in the goose. I've used it effectively for angioedema and tumors. I agree that video should weed out the simple anteriors and smaller tumors. And in my shops where there is no ENT and surgery will never see an airway without a department chief getting involved coming away with an ETT is significant.

 

[e30ftw]

I have run into the situation of can't intubate but can ventilate enough to buy some time way more often than the stone cold can't intubate, can't ventilate scenario. I cric immediately in that case. The retrograde is great for the situations where you can't see, either direct or with video, and the bougie keeps going in the goose. I've used it effectively for angioedema and tumors. I agree that video should weed out the simple anteriors and smaller tumors. And in my shops where there is no ENT and surgery will never see an airway without a department chief getting involved coming away with an ETT is significant.

Thanks Arcan and docB for responses. I've seen via bronchoscopy some airways that would be extremely difficult (impossible?) to intubate oro- or nasopharyngealy in an emergent scenario. In the situation where the neck anatomy is recognizable (and you're confident in cannulating the trachea) but based on your exam there is low probability of successful DL/VL even with the bougie and you can ventilate it would be reasonable to perform retrograde intubation.