Interesting Case

[Hoya11]

When I said spinal fails, I was referring to failing for whatever reason at procedurally placing the spinal while she's still on the stretcher. If the SAB was successful but the block isn't great or she's still moving significantly after a little more ketamine, I'd let her breathe down some sevo, keep her spontaneous, and slip in an LMA while she's still lateral.

TBH, I'm not super worried about her airway or a left-sided goiter if in my preop exam I find she's able to lie supine or right (operating) side up while breathing comfortably without auscultated stridor and still maintaining sp02 of 98 on RA as the OP says. Same goes for mediastinal masses- the history and physical exam is just as if not more important than what the CT looks like. People with critical airway narrowing at baseline don't have stone-cold normal physical exams- they just don't. That being said, if the plan was general I'd still most likely do a AFOI if her trachea was severely (sagittal diameter < ~5mm) narrowed on imaging but yet she (by some impossible chance) was showing no outward signs or symptoms.

i think ive failed to convey exactly how scary this airway was/big this goiter was.. a lateral lma with this airway.. no..

anyhow thanks for the interesting responses!

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[Arch Guillotti]

i think ive failed to convey exactly how scary this airway was/big this goiter was.. a lateral lma with this airway.. no..

Uh yeah no thanks on an LMA in the lateral position.

 

[Arch Guillotti]

Inducing one of these people (even inhalationally) is a lottery.

An inhalation induction is a disaster waiting to happen in this lady.

 

[Arch Guillotti]

And remember, positive pressure tends to help extra thoracic masses. This isn't an anterior mediastinal mass.

Are you sure about that?

 

[pgg]

Because it works, it’s enough. I intubate most of my patients with 30 of roc and usually don’t mask ventilate at all. I don’t consider it a half dose.

Agreed.

The ED95 of roc is 0.3 mg/kg. The "standard" 0.6 mg/kg and RSI 1.2 mg/kg doses are large.

Also, your average 90 yo LOL perhaps needs a dose of 0.0 mg/kg ...

 

[Arch Guillotti]

And if they are on a blood thinner is it absolutely contraindicated in every case ? This patient is a true potential can’t intubate/ventilate scenario who will not tolerate AWFIO 2/2 mental status. No matter how little you give for intubation if you lose the airway someone will say that you gave too much. Is the (likely theoretical) risk of a hematoma from a 25g (or even a 22) greater than the real risk of losing the airway? And what is the reason that this case can’t be delayed and the blood thinner reversed ?

Orthopedic surgeons don't want to wait unless they absolutely have to. None of them are going to wait 7 days for plavix to get washed out just because you want to do a spinal. With that being said, I know guys that have done a spinal on someone on plavix or whatever and didn't have any problem. Just make sure you have a clear discussion with the family and document accordingly.

 

[deleted162650]

Are you sure about that?

If there was a significant intrathoracic component I’d like to think that woulda been seen on CT and mentioned in the OP. And yes, PPV has the opposite effect on extra-thoracic masses than it does on intra-thoracic masses. I’m not necessarily saying paralyzing her is the world’s best idea, but trying maintain spontaneous ventilation isn’t as crucial here as it would be for an anterior mediastinal mass. These types of cases are so hard to Monday morning QB without actually seeing the patient and that gestalt feeling you get from just laying eyes on them.

 

[deleted162650]

i think ive failed to convey exactly how scary this airway was/big this goiter was.. a lateral lma with this airway.. no..

anyhow thanks for the interesting responses!

Why is she gonna be lateral for a hip nail or CRPP?? It’s not a hemi right?

 

[facted]

Why is she gonna be lateral for a hip nail or CRPP?? It’s not a hemi right?

Between the positioning and the supposition that all of a sudden she's on a blood thinner for some reason, this case has really morphed!

 

[2buckchuck]

It takes 5 minutes to numb the throat enough so that the patient can stick the glidescope down himself (I do it all the time when in doubt).

This intrigues me - can you explain how you topicalize patients?

 

[deleted171991]

This intrigues me - can you explain how you topicalize patients?

I start drying them up with 0.4 of glyco, 15-20 minutes before, suction their saliva and use four-by-four's to finish the job (as dry as possible), then use an atomizer with 4% topical lidocaine to numb up the pertinent areas systematically, also spraying down the throat and having the patient gag and gargle on it. I also use the atomizer as a probe, to test gagging. When there is no more gagging, I have the patient put the glidescope down his throat, so s/he is in control, and maybe ask them to vocalize. Most of the time, this is enough to see (what's above) the glottis.

It may not be enough for an AFOI, but I usually discover I won't need one. This all happens in the holding area.

 

[2buckchuck]

then use an atomizer with 4% topical lidocaine to numb up the pertinent areas systematically

It may not be enough for an AFOI

If you're using an atomizer, what areas are you hitting? Starting base of tongue, tonsils?

Also, you say it may not be enough for AFOI - what would you add for that?

 

[deleted162650]

If you put this lady to sleep and the airway collapses, just grab the damn goiter and pull up. Boom - obstruction gone/problem solved. Not sure why all you guys are so scared.

 

[deleted171991]

If you're using an atomizer, what areas are you hitting? Starting base of tongue, tonsils?

Also, you say it may not be enough for AFOI - what would you add for that?

Base of the tongue, tonsillar pillars, posterior wall of pharynx. For AFOI I will need some extra spraying using the suction port of the FO, as I go.

What I do is a variant of what Scott Weingart of Emcrit does: Awake Intubation for Emergency and Critical Care (watch the video). This is another example where some of our EM colleagues shine in areas that "belong" to other specialties. Their contribution, as a specialty, to free open-access medical education is just amazing.

Btw, I do the exact same thing (as for my awake looks) for EGDs and TEEs, especially in obese patients. These are mostly done by fellows, so they tend to take a while. Those few minutes of airway prep tend to save me a lot in propofol requirements, which matters a lot.

 

[2buckchuck]

Base of the tongue, tonsillar pillars, posterior wall of pharynx. For AFOI I will need some extra spraying using the suction port of the FO, as I go.

Do you go through any kind of conduit doing an AFOI?

Also, if you didn't have an atomizer, how would you MacGyver one?

 

[deleted171991]

Do you go through any kind of conduit doing an AFOI?

I tend to use a specialized airway, such as the Ovassapian. I don't want my patients to bite on the scope. But since I started doing awake glidescope looks, I find that I rarely need an AFOI for supraglottic lesions. See how they are doing awake laryngoscopy with the C-Mac in the video.

I still have to try doing an awake intubation with a glidescope and bougie, like they do. Thank God, I don't have many of these difficult airways in my practice.

If you don't have an atomizer, it's much more difficult. I would use a nebulizer instead, maybe coupled with some viscous lidocaine gargling, or some lidocaine on a tongue depressor, depending what you have available. What matters the most is to have everything DRY before you start topicalizing.

 

[deleted171991]

If you put this lady to sleep and the airway collapses, just grab the damn goiter and pull up. Boom - obstruction gone/problem solved. Not sure why all you guys are so scared.

If it doesn't have a substernal tail (hence the tracheal displacement).

 

[Psai]

If it doesn't have a substernal tail (hence the tracheal displacement).

Just attach the suction tubing to their neck, jack it up to high and pull up on it. Very easy.

 

[DrRobert]

Tracheostomy sounds like a pain in the arsenal.

No way I would ask ENT to be at the bedside nor would ENT want to be at the bedside.

I always ask ENT to be available for patients at high risk for surgical airways. Unless you feel comfortable doing a surgical airway, not consulting ENT (and a resulting bad outcome) is malpractice.

Had this case on Wednesday... 72M with oral cancer diagnosed 3 months ago who refused treatment. He did agree to a feeding tube only. Now presents with a septic knee requiring arthroscopy and washout. On exam his neck is full of large masses. Plan was for spinal anesthetic and ENT on standby for tracheostomy. Turns out he is on Eliquis for Afib. New plan is to wait 24 hours for Eliquis to clear so spinal can be safely placed. ENT still on standby for surgical airway in case of high spinal or airway obstruction. Case went smoothly with the spinal and ENT thanked us for consulting them early in the process.

 

[MoMoGesiologist]

I always ask ENT to be available for patients at high risk for surgical airways. Unless you feel comfortable doing a surgical airway, not consulting ENT (and a resulting bad outcome) is malpractice.

Had this case on Wednesday... 72M with oral cancer diagnosed 3 months ago who refused treatment. He did agree to a feeding tube only. Now presents with a septic knee requiring arthroscopy and washout. On exam his neck is full of large masses. Plan was for spinal anesthetic and ENT on standby for tracheostomy. Turns out he is on Eliquis for Afib. New plan is to wait 24 hours for Eliquis to clear so spinal can be safely placed. ENT still on standby for surgical airway in case of high spinal or airway obstruction. Case went smoothly with the spinal and ENT thanked us for consulting them early in the process.

How long can you delay a septic knee? Why not do an AFOI when he presented? Also if his neck is full of possibly friable/vascular masses, how easy would a trach be for a high spinal or airway obstruction? Asking for learning purposes

 

[narcusprince]

A solid ENT consult would be useful in this circumstance because they may be able to give you more information about intratracheal extension of the mass. Also they can be apart of the discussion of why a tracheostomy is not advised. At least medicolegaly you exhausted all options if anything should go bad. Still would do a spontaneous breathing inhaltion induction with a little ketamine. Spontaneous gluidescope with a reinforced tube. Family needs to know grandma has a high likelihood of not recovering. I like the idea of intubating with the dependant side down on the mass tilt l or right whichever way is dependent. A little prayer thats it.

 

[pgg]

I like the idea of intubating with the dependant side down on the mass tilt l or right whichever way is dependent.

Surely, you can't be serious.

 

[narcusprince]

Surely, you can't be serious.

If the mass is lateral to trachea left or right. Rotate the bed so the mass does not press on trachea. Kind of like LUD and intubate with glidedescope spontaneous breathing with ketamine and gas.