Learning Case

[militarymd]

Some of the history was obtained after the fact...some details have been changed or omitted to protect the innocent.

Old lady had ACDF 24 hours ago. She was doing fine, and getting ready to go home. She was finishing up her hospital lunch, and managed to gag on a piece of chicken.

The coughing spell which ensued caused her to develop a rapidly expanding hematoma in her neck.

She went from hard time swallowing to hard time breathing in minutes.....I got to watch her neck swell to bullfrog size before my eyes while I wheeled her emergently to an open OR.

On the way, I managed to snag extra help including other anesthesia folks, an ENT, and an OR crew.

By the time that we were in the OR, I was fairly confident that I would not be able to intubate her with a blade, and even more confident that I would not have time to do an awake fiberoptic intubation.

I slap the mask on her face, and told her that she might remember some of this and cranked the SEVO to 8 percent, and ask my ENT to cut the neck open.

While the surgeons are working, I squirt some Afrin in the nose and tried to get her more deeply anesthetized..kind of hard with a partially obstructed a/w.

When I thought she was ready, I tried to do a nasal fiber optic.....first mistake...patient wasn't deep enough....caused larygospasm and lost the airway.

Surgeons continue to work...I give sux and manage to re-establish a mask a/w. I gave DL one try....no view.

So I moved to an oral fiber...this goes in pretty easy...although airway anatomy was clearly not normal.

Case finishes ...patient does fine.....


Interesting point to me: patient ate a full meal...this full meal made her cough and caused the hematoma....

She had a mask induction.....She had an airway operation......She suffered through 3 different attempts at intubation before the airway was secured....absolutely no sign of aspiration...she didn't even vomit post op.

Seems to me that normal people with normal body habitus very rarely aspirate whether they have a full stomach or not....just my observation which doesn't sit well with the ASA's guidelines.

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[Noyac]

Were the surgeons going for an airway or control of her bleeding?

What did you do to resolve the laryngospasm? Sux? Pos Pressure?

Nice save, you stud. But I can't believe you took a full stomach to the OR and put her to sleep b/4 securing the airway.

 

[Planktonmd]

I wouldn't have done it your way but I agree about the aspiration risk,
It is way over rated.

 

[militarymd]

Were the surgeons going for an airway or control of her bleeding?

What did you do to resolve the laryngospasm? Sux? Pos Pressure?

Nice save, you stud. But I can't believe you took a full stomach to the OR and put her to sleep b/4 securing the airway.

I asked the surgeon to stop the bleeding....I hadn't asked for a trach...the last time I did this...I did ask for a trach.

The sux broke the spasm...

I didn't find out about the meal until after the case was over and I was talking to her husband..!!!!

I wished I had talked to him before surgery....then I would have cancelled her ass.

 

[Jeff05]

bad things:
1. induce a patient who clearly needs an awake FO
2. mask induce a full stomach
3. try to intubate a hematoma caused by cough without topicalization
4. paralyze a patient with an expanding neck hematoma

good things:
1. you were really lucky

 

[Arch Guillotti]

bad things:
1. induce a patient who clearly needs an awake FO
2. mask induce a full stomach
3. try to intubate a hematoma caused by cough without topicalization
4. paralyze a patient with an expanding neck hematoma

good things:
1. you were really lucky

Some days it is better to be lucky than good.

 

[bubalus]

bad things:
1. induce a patient who clearly needs an awake FO
2. mask induce a full stomach
3. try to intubate a hematoma caused by cough without topicalization
4. paralyze a patient with an expanding neck hematoma

I think that these are generally good ideas, particularly if you're going to give an oral boards answer. But sometimes your hand is forced and you have to play the cards you're dealt. Mil said he was "confident that I would not have time to do an awake fiberoptic intubation." So 1 is out the window. #2, he didn't know, and masking a full stomach is much better than an anoxic brain injury or death. I don't think Mil was interested in trying to topicalize an airway while the patient closed her's off. I'd say breaking laryngospasm is more important than not paralyzing a patient with an expanding neck hematoma.

Mil got dealt a sucky hand but with skill and luck managed to pull out a save. Adhering to dogma is fine if you live in a frictionless world, but when the fan is disturbed, you need to be able to adjust.

 

[Idiopathic]

whoa

i would have opened the incision at bedside before i would have dreamed about laryngoscopy.

obviously my inexperience

 

[Idiopathic]

.

 

[pd4emergence]

Seems to me that normal people with normal body habitus very rarely aspirate whether they have a full stomach or not....just my observation which doesn't sit well with the ASA's guidelines.

Hard for me to see the difference b/t breathing some sevo and giving a bunch of versed and ketamine as long as she keeps breathing on her own. I think once she spasmed you were stuck. No way to fix that other than what you did. Great case. As far as the body habitus thing and aspiration, if I see some one come to surgery with a normal body habitus it scares me so much that I just cancel them. If they don't have a BMI more than 40, I am just not comfortable doing the case.

pd4

 

[militarymd]

Hard for me to see the difference b/t breathing some sevo and giving a bunch of versed and ketamine as long as she keeps breathing on her own. I think once she spasmed you were stuck. No way to fix that other than what you did. Great case. As far as the body habitus thing and aspiration, if I see some one come to surgery with a normal body habitus it scares me so much that I just cancel them. If they don't have a BMI more than 40, I am just not comfortable doing the case.

pd4

could have...but didn't have time.

 

[jetproppilot]

bad things:
1. induce a patient who clearly needs an awake FO
2. mask induce a full stomach
3. try to intubate a hematoma caused by cough without topicalization
4. paralyze a patient with an expanding neck hematoma

good things:
1. you were really lucky

Very skilled clinicians get "lucky" all the time.

 

[coprolalia]

Very skilled clinicians get "lucky" all the time.

Yes. And, the subsequent humility expressed after they actually quite skillfully intubate that pregnant fireant and then say "I was lucky" speaks volumes about that person.



-copro

 

[dhb]

Was local anesthesia not an option to get control of the bleeding?
Did you have someone to help you providing jaw thrust when doing the oral fiberoptic?

Good save, you should have been at my place friday, the attending lost a difficult airway and subsequently the patient.

 

[militarymd]

Was local anesthesia not an option to get control of the bleeding?
Did you have someone to help you providing jaw thrust when doing the oral fiberoptic?

The case essentially started as a local, but rapidly became something that required GA.

As for help....I had a TON of it ....I pulled everyone I could to help me.

one attending was doing his best to provide jaw thrust without contaminated the field, and CRNA was holding the pink Williams airway steady in the midline while I drove the scope.

If I didn't have trained hands helping, I think the outcome would have been different.

 

[Tenesma]

i had a similar case during training except the patient was also in a HALO and was in the NEURO ICU (which is quite the distance from the OR) - on a weekend - the HALO was on because they felt her neck was still unstable they had done an anterior approach with the posterior lami/fusion to follow the next day....

by the time i got to the OR (the NEURO ICU fellow wanted me to do a DL w/ sux in the ICU... i snickered) her sats were in the 50s and she wasn't looking too pretty but still aware of her surroundings... we had a lido/epi nebulizer going over face while i got scope ready and the gen surg resident was prepping the neck... thank god the oral fiber went in on first try and we secured the airway...

the thought of cutting upen the incision doesn't help for these types of hematomas... the blood is usually retro-pharyngeal and won't necessarily decompress with opening the surgical wound (i have seen that tried before)...

as a side note - i believe anybody with a HALO should get an automatic trach... just makes sense...

 

[hokie]

I've had the McGrath (our new toy) save me in a similar situation recently.... it's fast becoming my go to device (and I'm a diehard fiberscope guy). I also like that I can put it in my back pocket when I run to the ICU
(No I don't have any financial interest in it...)

http://www.lmana.com/mcgrath.php

 

[lobelsteve]

Some of the history was obtained after the fact...some details have been changed or omitted to protect the innocent.

Old lady had ACDF 24 hours ago. She was doing fine, and getting ready to go home. She was finishing up her hospital lunch, and managed to gag on a piece of chicken.

The coughing spell which ensued caused her to develop a rapidly expanding hematoma in her neck.

She went from hard time swallowing to hard time breathing in minutes.....I got to watch her neck swell to bullfrog size before my eyes while I wheeled her emergently to an open OR.

On the way, I managed to snag extra help including other anesthesia folks, an ENT, and an OR crew.

By the time that we were in the OR, I was fairly confident that I would not be able to intubate her with a blade, and even more confident that I would not have time to do an awake fiberoptic intubation.

I slap the mask on her face, and told her that she might remember some of this and cranked the SEVO to 8 percent, and ask my ENT to cut the neck open.

While the surgeons are working, I squirt some Afrin in the nose and tried to get her more deeply anesthetized..kind of hard with a partially obstructed a/w.

When I thought she was ready, I tried to do a nasal fiber optic.....first mistake...patient wasn't deep enough....caused larygospasm and lost the airway.

Surgeons continue to work...I give sux and manage to re-establish a mask a/w. I gave DL one try....no view.

So I moved to an oral fiber...this goes in pretty easy...although airway anatomy was clearly not normal.

Case finishes ...patient does fine.....


Interesting point to me: patient ate a full meal...this full meal made her cough and caused the hematoma....

She had a mask induction.....She had an airway operation......She suffered through 3 different attempts at intubation before the airway was secured....absolutely no sign of aspiration...she didn't even vomit post op.

Seems to me that normal people with normal body habitus very rarely aspirate whether they have a full stomach or not....just my observation which doesn't sit well with the ASA's guidelines.

I see two small problems, though mostly due to my nievete.

1. What is an Anesthesiologist doing around this patient 24 hrs after surgery?
2. Is there any way of knowing which Anesthesiologist on staff would be the guy/gal to save my, my families, or my patients lives? As a Pain Doc, every pain doc I meet claims to be the worlds best needle jockey. We need a ranking system or I need to find My Own Jet in Canton GA. (Or Mil, Plankton, Copro, etc)

 

[militarymd]

I see two small problems, though mostly due to my nievete.

1. What is an Anesthesiologist doing around this patient 24 hrs after surgery?
2. Is there any way of knowing which Anesthesiologist on staff would be the guy/gal to save my, my families, or my patients lives? As a Pain Doc, every pain doc I meet claims to be the worlds best needle jockey. We need a ranking system or I need to find My Own Jet in Canton GA. (Or Mil, Plankton, Copro, etc)

1) I was doing post op rounds....so I was on the wards..the nurses got me

2) You ask the surgeons/OR nurses/techs....pretty much the folks who watch gas guys in action....who they would like to have take care of their family.


When people ask me who they should have take care of them, I tell them to ask the nurses.....I DO advise them on who NOT to have.