Along the same lines - a 70 year old patient s/p CEA for about 15 minutes in the PACU, starts have increased output from her drain - she is bleeding. She is laying flat and not stridorous and surgeon wants to take her back to the OR - how do you induce?
Laurel brings up a scenerio more important than the discussion thus far.
So far, we've been talking about what to do about a problem with a carotid with the tube still in.
A problem with a post-op carotid who is already extubated puts you in a perilous situation. You need
The Force to bring this patient to the OR, induce them and reestablish a secure airway.
Can't emphasize this enough.
Stridorous or not, this could get ugly. Really ugly.
Remove all distractions from your mind and focus cuz this is about as bad of a scenerio as you can imagine.
I once had an alternator failure in a single engine airplane (C-210) after climbing through a five-thousand-foot-thick, widespread, dense-but-smooth cloud layer to clear skies above....I knew I had about thirty minutes to get below the layer in order to reduce my chance of becoming a lawn dart....it was mostly 4000 ft overcast below so I knew I had some room underneath.....it was either that or fly endlessly, hoping for VFR weather somewhere amidst the huge front-induced-cloud-layer.....I put the re-inducing a carotid-case on the same level of concern as my alternator failure.
Read Noy's post again. I've been there too, Noy. Twice.
Even if some of the pressure has been relieved by opening the suture line,
the anatomy is going to look distorted. Be prepared for that. Don't expect to put the blade in and see two pearly-white vocal cords. Aint gonna happen. You're gonna see a swollen, distorted mess and you're gonna have to try and identify where the tube needs to go based on experience.
Knowing that in advance, have an array of tools available. Blades, bougie, whatever makes you feel comfortable. Some may consider an awake fiberoptic but not being able to identify anything while looking into an edematous mess will make this very challenging.
Remember what Noy said?......"I got lucky....", he said, referring to getting the tube in....I wouldnt call it luck, but point being even very experienced anesthesiologists are challenged by this scenerio. I felt the same way in both ugly-bring-back-CEAs I've been involved in.
You are crossing into no-man's land no matter how you handle this patient. If you induce with say, propofol and decide to try a non-paralyzed-awake look your conditions won't be optimized, you'll be looking into an edematous mess with very little time. If you induce and paralyze and cant intubate youre screwed. If you do an awake intubation your scope-skills must be deft and time is short. If you decide to try and do it under local the airway could be lost at any second.
No matter how you do it, the common denominator is you have
very little time. You gotta get the tube in and get it in quick. Or if under local be prepared to spring into action in a millisecond.
My preference would be to find the cricothyroid membrane before doing anything and marking it with a sharpie with the trusty jet ventilator setup ready to rock. If you're really concerned and you've got time, heck, call the ENT dude, tell him the scenerio, and plead with him to come stand in the room in case something goes awry. Do whatever makes you feel comfortable and do whatever you can to prepare in advance.
Anyway, I'd have the jet-ventilator ready, propofol 100mg or less, sux 40-60 mg. Boom. I've crossed into no-mans land. BOOM. The clock is ticking.
Hopefully I have
The Force.
Blade goes in. Search for something you can identify. Something big, like epiglottis. Use your right hand-on-the-Adam's-apple-trick to move the larynx left and right while looking for the "black hole" as Noy accurately described it. Cuz thats what the laryngeal opening will resemble now. A little black hole. Not a nice opening with cords on either side like youre used to seeing.
Lets say you intubate...hook up....uh oh....no ETCO2....esophagus.....
leave the tube in the esophagus and have someone hand you another one. Don't look up. Keep looking in. The esophageal ETT will now show you where not to go. Look higher. Look laterally. Keep manipulating the larynx with your right hand.
If you're unsuccessful, hopefully you can ventilate. Your induction meds will wear off quickly, but remember they're gonna wear off quickly and return you back to an ugly, stridorous situation.
Get to a point where you can't ventilate? Stick the crich with a big angiocath. Easier said than done in this scenerio.
Or revert to whatever your backup plan is....your ENT friend, or whatever you've planned.
There is no right answer on how to handle this scenerio. There are acceptable ways to handle it. As Mil has previously said in many posts, the "right" answer is the one that works.
I want to impress on all of you that this is one of the most concerning scenerios you will come upon as an anesthesiologist.
Tread carefully, have a plan and a backup plan, and yield
The Force.
