Let's Talk Airways

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I thought it would be interesting and informative to hear stories from you guys and girls about your most difficult airway scenarios.

What was the situation? What did you do? Outcome? Hopefully it can lead to some positive discussion about difficult airway management.

 

[Idiopathic]

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[Gas you down]

I thought it would be interesting and informative to hear stories from you guys and girls about your most difficult airway scenarios.

What was the situation? What did you do? Outcome? Hopefully it can lead to some positive discussion about difficult airway management.

walked by room in icu, see someone clearly undersedated, i mention it but 'thats the highest we can go on our protocols.' early 20s male s/p mva. jaw wired shut.
called later emergently to bedside as he has self extubated. blood pouring outta his nose, sats steadily dropping very low.
grab the bedside wire cutters, open his mouth...nothing, just edema and blood, even after copious suction.
emergent trach, Gen surg shows up (thank god). confirms yes we look ok w/ the trach... but not getting much ventilation in? suction ran down, brings up clot after clot but not getting bettter sats. starts to brady, so finally just run a small ETT down the trach like i'm cleaning out a drain, which seems to do the trick.
sats come up, i wipe my brow, then curse these bs protocols

 

[cincincyreds]

walked by room in icu, see someone clearly undersedated, i mention it but 'thats the highest we can go on our protocols.' early 20s male s/p mva. jaw wired shut.
called later emergently to bedside as he has self extubated. blood pouring outta his nose, sats steadily dropping very low.
grab the bedside wire cutters, open his mouth...nothing, just edema and blood, even after copious suction.
emergent trach, Gen surg shows up (thank god). confirms yes we look ok w/ the trach... but not getting much ventilation in? suction ran down, brings up clot after clot but not getting bettter sats. starts to brady, so finally just run a small ETT down the trach like i'm cleaning out a drain, which seems to do the trick.
sats come up, i wipe my brow, then curse these bs protocols

You'll probably be wiping something else after your code brown.

 

[Noyac]

Here's one from long ago:
I was on the ICU service as a CA1 when the OR brought a dwarf in intubated and sedated after attempting an anterior and posterior cervical fusion. Apparently, they got into some bleeding they couldn't control fast enough while on the anterior portion of the case. The problem is that this dwarf was a Jehovah's Witness and her hct had fallen to 12 during the case. She was brought to us intubated to allow her to rebound and return to the OR once her hct was better. So as you can imagine she got a ton of fluids to maintain BP and she started to swell beyond imagination. About a week later we are rounding and the pt is heavily sedated and possibly restrained ( I can't recall) because the last thing we need is for her to extubate herself since she is so edematous and her neck is completely unstable. Basically, they decompressed the spinal cord, got into the bleeding and had to pack the wound and close with the hopes of returning in a few days. But we all know it takes weeks for the hct to respond to epo. So their plans were **** from the start. We are rounding on the pt and the ICU RN gets the bright idea that we exchange the nasal ETT for an oral one so she doesn't get infected. The ICU team laughed a bit and said no F'in way. She is way too swollen and unstable. About 30 minutes later we are wrapping up rounds on the unit and we get called urgently to bed 18. The poor lady is extubated. WTF!

So who wants to take the head of the table and get this lady reintubated? Oh her sats are falling.

 

[proman]

Here's one from long ago:
I was on the ICU service as a CA1 when the OR brought a dwarf in intubated and sedated after attempting an anterior and posterior cervical fusion. Apparently, they got into some bleeding they couldn't control fast enough while on the anterior portion of the case. The problem is that this dwarf was a Jehovah's Witness and her hct had fallen to 12 during the case. She was brought to us intubated to allow her to rebound and return to the OR once her hct was better. So as you can imagine she got a ton of fluids to maintain BP and she started to swell beyond imagination. About a week later we are rounding and the pt is heavily sedated and possibly restrained ( I can't recall) because the last thing we need is for her to extubate herself since she is so edematous and her neck is completely unstable. Basically, they decompressed the spinal cord, got into the bleeding and had to pack the wound and close with the hopes of returning in a few days. But we all know it takes weeks for the hct to respond to epo. So their plans were **** from the start. We are rounding on the pt and the ICU RN gets the bright idea that we exchange the nasal ETT for an oral one so she doesn't get infected. The ICU team laughed a bit and said no F'in way. She is way too swollen and unstable. About 30 minutes later we are wrapping up rounds on the unit and we get called urgently to bed 18. The poor lady is extubated. WTF!

So who wants to take the head of the table and get this lady reintubated? Oh her sats are falling.

I'd want to know the nurse's alibi. Seems highly coincidental.

 

[Noyac]

I'd want to know the nurse's alibi. Seems highly coincidental.

The site of her balling in the corner of the room was enough.

 

[Noyac]

anyone want to address the airway? How about some of you new residents or med studs?

 

[G0S2]

Shes gonna die. Urgently page ENT/surgeons to room along with crash cart and airway cart (should be in every ICU). I would get behind her and try to manually ventilate and if I can't move air start the ASA algo and try a LMA. If thats a no go and shes really falling, its surgical airway time. If I can ventilate with a LMA, I would place a pedi FOB through an Aintree and try to place the cath through the cords. Once in, intubate over the cath. I would also ask for a Glidescope and try a DL.

Basically, GET HELP!! Stay calm and try your best to ventilate. If you can't its surgical airway time, which in this pt will most likely end in disaster.

 

[WholeLottaGame7]

Shes gonna die. Urgently page ENT/surgeons to room along with crash cart and airway cart (should be in every ICU). I would get behind her and try to manually ventilate and if I can't move air start the ASA algo and try a LMA. If thats a no go and shes really falling, its surgical airway time. If I can ventilate with a LMA, I would place a pedi FOB through an Aintree and try to place the cath through the cords. Once in, intubate over the cath. I would also ask for a Glidescope and try a DL.

Basically, GET HELP!! Stay calm and try your best to ventilate. If you can't its surgical airway time, which in this pt will most likely end in disaster.

A) This can't possibly be real, but I'll bite.
2) I agree with above, though considering the fluid/anatomy/surgical issues, it sounds like this is going to end up with a surgical airway regardless. If I could somehow miraculously ventilate either manually or with an LMA, I'd probably hold tight until surgery was available. Ventilating will keep her alive, trying to get cute and intubate her and you could off her pretty quick.

Cutting her neck sounds like a cluster, but I wonder if you could just needle cric her and buy time until the cavalry arrives.

 

[Noyac]

A) This can't possibly be real, but I'll bite.
2) I agree with above, though considering the fluid/anatomy/surgical issues, it sounds like this is going to end up with a surgical airway regardless. If I could somehow miraculously ventilate either manually or with an LMA, I'd probably hold tight until surgery was available. Ventilating will keep her alive, trying to get cute and intubate her and you could off her pretty quick.

Cutting her neck sounds like a cluster, but I wonder if you could just needle cric her and buy time until the cavalry arrives.

What makes you say this is going to end up in a surgical airway?

Please elaborate on the fluid/anatomy/surgical issues. It does the newbies no good to just mention them in passing.

so lets say you can ventilate but its difficult and getting worse. Surgery is "on the way". Watcha gonna do? What if they take too long?

 

[WholeLottaGame7]

What makes you say this is going to end up in a surgical airway?

Please elaborate on the fluid/anatomy/surgical issues. It does the newbies no good to just mention them in passing.

so lets say you can ventilate but its difficult and getting worse. Surgery is "on the way". Watcha gonna do? What if they take too long?

That's just me guessing as to where this is heading. I'm presuming that A) when you try to bag, you can't, 2) when you put in an OPA/NPA, you still can't bag, #)when you try the LMA, it won't seat/can't ventilate, 4) when you try to videoscope or FOB her, there's too much soft tissue.

As for the other issues, she's received a crapload of fluid over the past several days, I'm sure, making the soft tissues of her pharynx and neck super edematous, plus the inflammation from the ETT. I haven't done a neuro rotation yet nor do I know exactly where the surgeons left it, but I'm thinking that you don't want to do a whole lot of C-spine manipulation in this patient out of regards for the spinal cord/surgical field. And I haven't looked up anesthetic implications of dwarfism (though I probably will now out of curiousity), but I would guess that they at least have limited ROM to start with.

I would certainly try the first 3 things I mentioned above, then probably take a look with a videoscope to see if I could at least pass a ventilating exchange catheter of your choosing (we have Frovas). Not super comfortable with a FOB at this stage in my training, but like I said I'm guessing that would be fruitless anyway.

I don't know that I would go cutting on her neck because it seems like it would be a squishy (diluted)-bloody mess. I would think you might have better luck getting a needle into her trachea and trying to jet ventilate her at least long enough for surgery to get there.

Given the potential for said disaster, I wonder if traching the patient empirically wouldn't have been the worst thing worst thing in the world, though I'm sure surgery would be like "no no, we're going to be taking her back to the OR tomorrow" for about 7 days in a row.

 

[proman]

The site of her balling in the corner of the room was enough.

Ok, the cynic in me would have first thought otherwise.

As for management, I'd go straight to an LMA. Chances are you didn't have a Glidescope around. Like someone else said, I'd then consider fiberoptic/Aintree but only after things settled out.

 

[pd4emergence]

Chances of an lma working are slim. I would for sure still try it, if you can get it in. My guess is that this was a while ago and widespread use of a video laryngoscope had not happened. Now I would try a combined glidescope/foi but with both of these you have to be able to see something, this too may be less than successful here. I think that leaves trying a retrograde or perc cric or some other trans tracheal means of oxygenation

 

[Noyac]

Chances of an lma working are slim. I would for sure still try it, if you can get it in. My guess is that this was a while ago and widespread use of a video laryngoscope had not happened. Now I would try a combined glidescope/foi but with both of these you have to be able to see something, this too may be less than successful here. I think that leaves trying a retrograde or perc cric or some other trans tracheal means of oxygenation

Very good but you are an attending and we all expect the right answer from you, sucks don't it.
I'll tell you that there was no such thing as a glide scope back then and this wasn't that long ago.

 

[pd4emergence]

Very good but you are an attending and we all expect the right answer from you, sucks don't it.
I'll tell you that there was no such thing as a glide scope back then and this wasn't that long ago.

Sorry, didn't mean to spoil it. It was very short sighted of me. But you have to admit the list of options here is very short. I will do my best not to shorten the thread further. I did a thread search and there are a very select few that mention dwarves and they all seem to be rather short.

 

[somedumbDO]

Worst airway in my career. 8 yr old Craniopegus twins. Attached forehead to occiput. Cranial angiography and embolization with possible separation. Twin A: hypertensive DBP @ 100 and shunt 15% CO to twin B via MCA -> ACA, Questionable reversal of shunt between twin B-> twin A due to venous connection of EJ to unknown vasculature. Twin B: Hypotensive at baseline pressures 50-40 systolic at baseline renal agenisis. Both normal mentation and neural function at baseline. Both MP 4 due to positioning, decent C spine function but tethered obviously. Jaw is normal. Both patients are highly agitated/nervous due to previous death talk w/ surgeon. Labs WNL. Cardiovascular system WNL, Normal lungs. No anesthetic records previous care was done in Romania. Had anesthesia before adoptive parents have no idea about any issues.

what would you do next?