My first airway disaster

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Bostonredsox

Bostonredsox

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53 y/o male presents to Ed with progressive dyspnea and dysphasia with swollen throat feeling of about 8 hours. Started ACEI 3 weeks ago. Ed doc sees unilateral angioedema. Airway otherwise intact. Spo2 99% on 2L. Calls for MICU admit for obs overnight with ent to see in the unit, the were currently unavailable. He is one of 3 admits in. 40 min span. We give bridge orders, he makes it up about 30 min later.

About 10 min after arrival to MICU, nurse asks me to come see him as he's complaining of more dyspnea, I'm finishing an art line. Come over, see his grade 4 from the doorway with tongue almost protruding and drooling.

Page anesthesia stat and to come with glide.

Tell him he needs a tube if he doesn't want to die.

Gas gets here. Prop/sux no view. No cords anywhere. Edema everywhere. He withdraws and bags sats mid 80s looks again and tries to pass tube where cords should be. Nothing. Sats high70s. Pt waking up. I call GS stat. Bedside trach in 5 min later. 6.0 barely fit in.

For residents who have yet to see an angioedema.....these fu^*+rs can tank fast. 15 min talking and ventilating fine to a nearly completely closed train wreck airway.

Was wild. Was hoping to get a crack at retrograde but surg got there fast and went right to the definitive airway.
 
At the institutions we cover, these patients go to the OR for intubation by anesthsia, with ENT there as back up.

As far as managing the airway, awake FOI, I like trans tracheal lido 2-3ml, dilate the nostril with lido lubed nasal trumpet. Nasal intubation via fiber optic then put them to sleep once the tube is confirmed. I see angiooedema quite a bit of this, with The patient population I serve (AA, Caribbean Americans).

I understand in your case ENT wasn't in house, but they should be readily available as these pts can crump out and may need a surgical airway (I guess that's why the EM docs almost immediately call us and ENT for intubation and not play a wait and see approach). Why weren't they called in and the pt taken to the OR? At your shop, are these pts routinely admitted without the airway being secured?
 
Had a case in residency similar to this. I was holding the code pager and get called to the ED to "back up" the ED doc. 75 yo guy with HTN, Cad, Dm and mild dementia whose wife found him in the bathroom with trouble breathing an some expired meds nearby. I get there and the guys tongue looked like roast beef sticking out if his mouth. The ERIC attending lets his resident give it a crack over our objections but after a struggle with a glide he gets the tube in. Two minutes later in the elevator we hear anesthesia and ENT stat to ED. The ED got the chest X-ray and the tube wasn't in, the guy was now vomiting through the tube and sats were falling. We get there and have a quick look with fiber optic but can't see a thing; meanwhile ENT have localized the neck and is ready to cut. They get the airway and the resident straddles him while the guy is wheeled to the OR to clean it up. Lessons of the story: respect the situation, it was not the time to let a trainee give it a go, always know where you put the tube and don't just guess its in.

Ps. We got the guys records later from an OSH and it turns out he had a history of angioedena to ACEIs. Wife said he must have found some in the med cabinet and got confused.
 
Bostonredsox said:
53 y/o male presents to Ed with progressive dyspnea and dysphasia with swollen throat feeling of about 8 hours. Started ACEI 3 weeks ago. Ed doc sees unilateral angioedema. Airway otherwise intact. Spo2 99% on 2L. Calls for MICU admit for obs overnight with ent to see in the unit, the were currently unavailable. He is one of 3 admits in. 40 min span. We give bridge orders, he makes it up about 30 min later.

About 10 min after arrival to MICU, nurse asks me to come see him as he's complaining of more dyspnea, I'm finishing an art line. Come over, see his grade 4 from the doorway with tongue almost protruding and drooling.

Page anesthesia stat and to come with glide.

Tell him he needs a tube if he doesn't want to die.

Gas gets here. Prop/sux no view. No cords anywhere. Edema everywhere. He withdraws and bags sats mid 80s looks again and tries to pass tube where cords should be. Nothing. Sats high70s. Pt waking up. I call GS stat. Bedside trach in 5 min later. 6.0 barely fit in.

For residents who have yet to see an angioedema.....these fu^*+rs can tank fast. 15 min talking and ventilating fine to a nearly completely closed train wreck airway.

Was wild. Was hoping to get a crack at retrograde but surg got there fast and went right to the definitive airway.
Click to expand...

I have some issues with the mangement of this patient.

As you just said, angioedema should be taken as an airway emergency as they can crump super fast. I have seen 2 cases. One as resident and one as an attending. I don't think this patient should have ever left the ED until his airway was secured unless he was going to the OR with anesthesia/ENT to secure the airway. These patients can deteriorate right in front of you. When you see this patient, a cric/trach kit should be at the bedside immediately. So I do not understand the reasoning of admitting the patient for OBS in the MICU and have ENT see him in the MICU.

What you are going to observe is he is going to get worse and completely obstruct.

Next issue is the RSI and GS attempt. Grade IV view very likely that is ... if you can even get the blade in the mouth. Ventilation is going to be extremely difficult or impossible. I don't agree with RSI in this situation. With patient awake and breathing although dyspneic this is a nasal FO intubation, and ENT should be there, if not someone skilled at trach.

The case I saw in residency the pt's tongue was protruding out so much it was scary. ENT came in quickly and nasally intubated with no topicalization and did it in like 12 seconds.

My case as an attending I get called late at night at home while I am on pager call. ED doc says angioedema pt is dyspneic but currently stable, but he needs my help for intubation. My words, "do not electively induce this patient for intubation. We will plan for nasal fiberoptic. I am on my way". On exam pt had decent mouth opening. ED doc stated pt became combative and was obstructing more so he put nasal trumpet and she settled down. Explain to pt urgent need for intubation and possible discomfort with nasal intubation. Transtracheal and SLN block. Lidocaine jelly nasal tumpets. ETT goes in nostril. I get the FO. ED doc advances tube and says, "I think we're in". We can hear air moving through tube. ETCO2 color change. FO confirms tube above carina.

The old blind nasal

I spoke with that patient after the ordeal when she got extubated. She stated that she came to ED for a weird tongue swelling she started feeling, and within 2 hours it looked like what I saw in the ED. 2 HOURS!!!

When I saw her, she could still open her mouth. Can you imagine what it would look like an hour later???

Angioedema is airway emergency even if patient looks "OK" when you see them because it is going to go downhill. Don't be shy of securing the airway early. Nasal FO intubation is excellent in this situation
 
It is always hard judging decisions in complicated clinical situations but I agree this sounds like an attempt at awake FOI or awake trach....and in the event that the decision was made to induce and paralyze I would without question have a cric kit sitting close or even better ENT/general surgery at bedside. "Tongue protruding and drooling" and the words induction would make me really nervous and would want plan B,C,D seconds away.
 
excalibur said:
I have some issues with the mangement of this patient.

As you just said, angioedema should be taken as an airway emergency as they can crump super fast.... I don't think this patient should have ever left the ED until his airway was secured unless he was going to the OR with anesthesia/ENT to secure the airway. These patients can deteriorate right in front of you. When you see this patient, a cric/trach kit should be at the bedside immediately. So I do not understand the reasoning of admitting the patient for OBS in the MICU and have ENT see him in the MICU.

What you are going to observe is he is going to get worse and completely obstruct.

Next issue is the RSI and GS attempt. Grade IV view very likely that is ... if you can even get the blade in the mouth. Ventilation is going to be extremely difficult or impossible. I don't agree with RSI in this situation. With patient awake and breathing although dyspneic this is a nasal FO intubation, and ENT should be there, if not someone skilled at trach.
Click to expand...

Agreed.

Too many people waste too much time with angioedema when they should be expeditiously intubated. I also see too many patients getting epi/benadryl/steroids which won't help.
 
Totally agree with you guys. My attending took this call from Ed attending as I was in procedure. Apparently between her and Ed attending they felt he was a mild angioedema and was given decadron/Pepcid/Benadryl with a plan for monitoring. Clearly they misjudged his level of angioedema.

Ent was on diversion and the Ed managed to get ahold of one of them who was returning from out of the area and that he could see the pt later in the evening when he got back to town. I would have asked for a FOI (I think our gas guys do that,cmight be only ent here though don't know) with GS at bedside for trach but I didn't field that call and my more experienced than me attendings felt he was ok to roid up and watch

I also totally agree with no RSI. When he setup the glide and asked for prop and sux my ******* tightened up real fast. In my head I was like wtf??? Your gonna paralyze this monstrosity? Now he was relatively easy to ventilate at first so maybe he was thinking quick on quick off prop/sux if I see nothing bag through it and come up with a plan b. but it scared the **** out of me.

The only thing I can say from my standpoint to other residents is that as anIM senior resident who is not yet a pulm/CC fellow but is otherwise known as relatively cavalier with procedures, there was no way I was attempting that airway even if I had a glide of my own in the MICU. When I'm proficient at emergent trach ok I'll give it a go. Maybe. But at this point, there is no way I'm risking death for a 53 y/o healthy guy so I can attempt a difficult airway such as this one. No your limits and no when to set pride aside and get help.
 
Agree with above--almost ALWAYS, angioedema should be considered emergent. Patients rarely do well for long and when they crump, it's all the way--straight downhill in a hurry with little airway upside at that point. FWIW, the last 3 I've done, I abandoned the fancy neck blocks and did straight topical/nebs/glyco + FO and my new fav for AFO-----Precedex!!! Pts settle in sedate and cooperative, but more importantly, without significant resp compromise. It just seems smoother. Again, recent N=3 but they were much cleaner than my previous recipe.
 
soonerfrog said:
... and my new fav for AFO-----Precedex!!! Pts settle in sedate and cooperative, but more importantly, without significant resp compromise. It just seems smoother. Again, recent N=3 but they were much cleaner than my previous recipe.
Click to expand...

What was your previous recipe? Ketamine?
 
These are the types of cases that should be presented at m and m's. the management was wrong on multiple levels. A patient will die in your institution if the handling of this type of scenario in this way occurs repeatedly.
 
Bostonredsox said:
About 10 min after arrival to MICU, nurse asks me to come see him as he's complaining of more dyspnea, I'm finishing an art line. Come over, see his grade 4 from the doorway with tongue almost protruding and drooling.

Page anesthesia stat and to come with glide.

Tell him he needs a tube if he doesn't want to die.

Gas gets here. Prop/sux no view. No cords anywhere. Edema everywhere. He withdraws and bags sats mid 80s looks again and tries to pass tube where cords should be. Nothing. Sats high70s. Pt waking up. I call GS stat. Bedside trach in 5 min later. 6.0 barely fit in.
.
Click to expand...

I am curious... what was the reasoning behind inducing GA and apnea on this looming disaster?
 
I second that. Whoever decided to do propofol/sux in a tongue-protruding angioedema patient should just throw his/her medical license in the shredder at the same time
 
This has AWAKE fiberoptic nasal intubation written all over it. I had a very similar case at the VA. Went very smooth. Angioedema is not something to mess around with. BTW, Precedex is the awesomenest!
 
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This is a case of what I would term mental masturbation. Was this anesthetic performed at a harvard hospital?
 
Dude like that: call code, get team, move to OR stat for airway management. sounded like trach from the getgo once you saw him in unit. prop sux in the unit wrong. in the or, wrong. awake with surgeon ready to cut: right.
 
This is a great educational case-- the only thing patients with angioedema, epiglottitis, inhalational injury with upper airway swelling, etc. have going for them is their ability to BREATHE SPONTANEOUSLY. Our job is to do everything in our power to maintain that. In an adult, awake fiberoptic in the OR. In a kid, ketamine or breathe down with sevo in the OR. One of the few contraindications to paralytic.

Neck should be prepped and ready to go. If there's no ENT available, be ready to cric or find another surgeon willing to be at the bedside to trach. These patients are no joke-- in fact they should be assumed to be nightmares if drooling, sniffing position or tripoding is in the equation.

If someone disagrees with you and you are worried-- stand your ground-- these are not the cases to give in. I've stood my ground as a fellow in 2 cases where people wanted to do RSIs in the ED on kids for airway swelling and I insisted on going to the OR for a spontaneously ventilating sevo induction, both ended up emergently trached in the OR due to donut epiglottis with no hole. One was thermal epiglottitis due to steam injury, another was angioedema.

Paralytic is your worst friend here. Spontaneous ventilation is keeping them alive.

Thanks for sharing the case and bringing up a very important teaching topic.
 
ProwlerturnGas said:
This has AWAKE fiberoptic nasal intubation written all over it. I had a very similar case at the VA. Went very smooth. Angioedema is not something to mess around with. BTW, Precedex is the awesomenest!
Click to expand...

Any reason not to do oral awake FOI assuming you can place an ovassapian airway?
 
What would be the oral board answer to angiooedema with ENT not readily available? Awake fiber optic without a surgeon available for surgical airway?

What about in the real world. How would you proceed if you're in house and there isn't a surgeon available and you have a patient like this presenting? What are the medico-legal implications if you do or don't proceed with emergency intubation and the airway is lost?

A couple of weeks ago on a Sunday call, we had an anigoedema secondary to ARB use. There wasn't a surgeon in house and only a 3rd year ENT resident in the ED. The resident was adamant about the pt going to the OR for intubation, with him as backup (ENT attending was at home with Sunday traffic 1 hr away). The attending on call was about to cave and do the intubation, but IMO came to his senses and waited for the attesting to arrive (of note the pt had no neck and was recently intubated for presumedly the same reason, but that's another story). He was 'stable' until we proceeded, but what would you guys (and gals) would have done if he started to decompensate and only a junior resident available?
 
Oral fiberoptic is reasonable. Awake is the key. In my experience with these angioedema cases, tongue much too swollen and woody to attempt.
 
HumidifiedMoistureExchange said:
What would be the oral board answer to angiooedema with ENT not readily available? Awake fiber optic without a surgeon available for surgical airway?

What about in the real world. How would you proceed if you're in house and there isn't a surgeon available and you have a patient like this presenting? What are the medico-legal implications if you do or don't proceed with emergency intubation and the airway is lost?

A couple of weeks ago on a Sunday call, we had an anigoedema secondary to ARB use. There wasn't a surgeon in house and only a 3rd year ENT resident in the ED. The resident was adamant about the pt going to the OR for intubation, with him as backup (ENT attending was at home with Sunday traffic 1 hr away). The attending on call was about to cave and do the intubation, but IMO came to his senses and waited for the attesting to arrive (of note the pt had no neck and was recently intubated for presumedly the same reason, but that's another story). He was 'stable' until we proceeded, but what would you guys (and gals) would have done if he started to decompensate and only a junior resident available?
Click to expand...

Awake FOI nasal with lido/epi local, bougie, #11 blade, and 6.0 ett at the ready for cric.
 
VentdependenT said:
Dude like that: call code, get team, move to OR stat for airway management. sounded like trach from the getgo once you saw him in unit. prop sux in the unit wrong. in the or, wrong. awake with surgeon ready to cut: right.
Click to expand...

absolutely. this is OR trach and a "youre welcome" as he leaves the hospital in a few days.

also, retrograde is a possible solution to this but you had better be able to fit a tube through that edema or youve lost about 90 seconds minimum. if you are poking a hole in the neck just poke a bigger one and jet -> trach
 
HumidifiedMoistureExchange said:
What would be the oral board answer to angiooedema with ENT not readily available? Awake fiber optic without a surgeon available for surgical airway?

What about in the real world. How would you proceed if you're in house and there isn't a surgeon available and you have a patient like this presenting? What are the medico-legal implications if you do or don't proceed with emergency intubation and the airway is lost?

A couple of weeks ago on a Sunday call, we had an anigoedema secondary to ARB use. There wasn't a surgeon in house and only a 3rd year ENT resident in the ED. The resident was adamant about the pt going to the OR for intubation, with him as backup (ENT attending was at home with Sunday traffic 1 hr away). The attending on call was about to cave and do the intubation, but IMO came to his senses and waited for the attesting to arrive (of note the pt had no neck and was recently intubated for presumedly the same reason, but that's another story). He was 'stable' until we proceeded, but what would you guys (and gals) would have done if he started to decompensate and only a junior resident available?
Click to expand...

I would think that since this is a situation that you should know and that you should rehearse and given that you are likely the airway expert its pretty important. with that said, some things are not salvageable, and even the best plan can lead to a negative outcome.

why would you proceed any differently as a junior resident than you would as an attending in an emergency? obviously it would be outside your comfort zone, but it would be outside many of our comfort zones, honestly. awake procedure with topicalization and non-sedating anxiolysis, load the FOI with an aintree or the smallest tube that will fit, have a knife ready to go in case he decompensates and refersh yourself on perc and slash trachs. CALL ANYONE ELSE TO HELP. Get your PGY-2 surgeon friend at the bedside.
 
excalibur said:
I have some issues with the mangement of this patient.

As you just said, angioedema should be taken as an airway emergency as they can crump super fast. I have seen 2 cases. One as resident and one as an attending. I don't think this patient should have ever left the ED until his airway was secured unless he was going to the OR with anesthesia/ENT to secure the airway. These patients can deteriorate right in front of you. When you see this patient, a cric/trach kit should be at the bedside immediately. So I do not understand the reasoning of admitting the patient for OBS in the MICU and have ENT see him in the MICU.

What you are going to observe is he is going to get worse and completely obstruct.

Next issue is the RSI and GS attempt. Grade IV view very likely that is ... if you can even get the blade in the mouth. Ventilation is going to be extremely difficult or impossible. I don't agree with RSI in this situation. With patient awake and breathing although dyspneic this is a nasal FO intubation, and ENT should be there, if not someone skilled at trach.

The case I saw in residency the pt's tongue was protruding out so much it was scary. ENT came in quickly and nasally intubated with no topicalization and did it in like 12 seconds.

My case as an attending I get called late at night at home while I am on pager call. ED doc says angioedema pt is dyspneic but currently stable, but he needs my help for intubation. My words, "do not electively induce this patient for intubation. We will plan for nasal fiberoptic. I am on my way". On exam pt had decent mouth opening. ED doc stated pt became combative and was obstructing more so he put nasal trumpet and she settled down. Explain to pt urgent need for intubation and possible discomfort with nasal intubation. Transtracheal and SLN block. Lidocaine jelly nasal tumpets. ETT goes in nostril. I get the FO. ED doc advances tube and says, "I think we're in". We can hear air moving through tube. ETCO2 color change. FO confirms tube above carina.

The old blind nasal

I spoke with that patient after the ordeal when she got extubated. She stated that she came to ED for a weird tongue swelling she started feeling, and within 2 hours it looked like what I saw in the ED. 2 HOURS!!!

When I saw her, she could still open her mouth. Can you imagine what it would look like an hour later???

Angioedema is airway emergency even if patient looks "OK" when you see them because it is going to go downhill. Don't be shy of securing the airway early. Nasal FO intubation is excellent in this situation
Click to expand...

Some angioedema is an airway emergency. There's a spectrum of disease and the majority of angioedema is just lip swelling that does not require anesthesia or (usually) admission. I'll agree that anytime you guys are being called it is an emergency, and I prefer to have the airway secured in the OR or at least with an ENT ready to do a trach at bedside. In the handful of cases that have occurred at shops I've worked at that have gone bad, the patient's respiratory failure occurred well after the ability to intubate from above has vanished.
 
excalibur said:
I have some issues with the mangement of this patient.

As you just said, angioedema should be taken as an airway emergency as they can crump super fast. I have seen 2 cases. One as resident and one as an attending. I don't think this patient should have ever left the ED until his airway was secured unless he was going to the OR with anesthesia/ENT to secure the airway. These patients can deteriorate right in front of you. When you see this patient, a cric/trach kit should be at the bedside immediately. So I do not understand the reasoning of admitting the patient for OBS in the MICU and have ENT see him in the MICU.

What you are going to observe is he is going to get worse and completely obstruct.

Next issue is the RSI and GS attempt. Grade IV view very likely that is ... if you can even get the blade in the mouth. Ventilation is going to be extremely difficult or impossible. I don't agree with RSI in this situation. With patient awake and breathing although dyspneic this is a nasal FO intubation, and ENT should be there, if not someone skilled at trach.

The case I saw in residency the pt's tongue was protruding out so much it was scary. ENT came in quickly and nasally intubated with no topicalization and did it in like 12 seconds.

My case as an attending I get called late at night at home while I am on pager call. ED doc says angioedema pt is dyspneic but currently stable, but he needs my help for intubation. My words, "do not electively induce this patient for intubation. We will plan for nasal fiberoptic. I am on my way". On exam pt had decent mouth opening. ED doc stated pt became combative and was obstructing more so he put nasal trumpet and she settled down. Explain to pt urgent need for intubation and possible discomfort with nasal intubation. Transtracheal and SLN block. Lidocaine jelly nasal tumpets. ETT goes in nostril. I get the FO. ED doc advances tube and says, "I think we're in". We can hear air moving through tube. ETCO2 color change. FO confirms tube above carina.

The old blind nasal

I spoke with that patient after the ordeal when she got extubated. She stated that she came to ED for a weird tongue swelling she started feeling, and within 2 hours it looked like what I saw in the ED. 2 HOURS!!!

When I saw her, she could still open her mouth. Can you imagine what it would look like an hour later???

Angioedema is airway emergency even if patient looks "OK" when you see them because it is going to go downhill. Don't be shy of securing the airway early. Nasal FO intubation is excellent in this situation
Click to expand...

Some angioedema is an airway emergency. There's a spectrum of disease and the majority of angioedema is just lip swelling that does not require anesthesia or (usually) admission. I'll agree that anytime you guys are being called it is an emergency, and I prefer to have the airway secured in the OR or at least with an ENT ready to do a trach at bedside. In the handful of cases that have occurred at shops I've worked at that have gone bad, the patient's respiratory failure occurred well after the ability to intubate from above has vanished.
 
You can discuss the spectrum of angioedema all you want but in all seriousness...

Angioedema with progressive dyspnea (from OP's history) is an airway emergency. PERIOD. A ball was dropped by shipping pt to MICU. Second ball dropped for choosing RSI.

Angioedema pt who presents to the ED with dyspnea or dysphagia or dysphasia or drooling is an airway emergency in my opinion
 
I've done this case a handful of times (I think I started a thread on one of them 3-4 years ago). True agioedema = tough AW. Sometimes doing nothing is the best option. Sometimes you DL. Sometimes you go straight to trach. If you really are concerned and you have a difficult trach, you could go as far as ECMO.

Everytime I've come across it, ENT is there or I have called them in. I also take them to the OR.

It only takes one lost AW...
 
Idiopathic said:
absolutely. this is OR trach and a "youre welcome" as he leaves the hospital in a few days.

also, retrograde is a possible solution to this but you had better be able to fit a tube through that edema or youve lost about 90 seconds minimum. if you are poking a hole in the neck just poke a bigger one and jet -> trach
Click to expand...

can we just forget about that retrograde crap and aknowledge that in the real world it just does not work???
 
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You guys don't even know the depth of failure here.

Ok. So some follow up.

I found out...the guy had come to Ed 3 days earlier, ACEI was not stopped, he was given medrol dose pack and SENT HOME!!!

Second new item. The anesthesiologist that prop/suxed.....turns out he is/was an ENT. Sounds like he converted to gas, not sure if he did a second residency like venty or was grandfathered with an extra year or something but he's the main gas guy for the heart patients and he used to have an ent practice many years ago. So I'd assume he was comfortable with trach, and he did call for a trach kit as soon as he saw nothing in the first glide look.

I spoke with a few other off my gas friends and they all told me awake FOI same as you. Ok to go to MICU and do FOI there so long as you have surgeon who can trach at bedside.

To add even more....about 6pm tonight he started pulling no tidal volumes and was looking more swollen. I listened to him, crepitus all over. Stat film, no PTX but subq air all over the mediastinum. Paged surgeons stat, exchanged trach over bougie for a longer neck trach, but downsized caliber from 8 to 7 was to edematous for 8. Doing better now.

Talked with my MICU director, she asked me to present it as an m and m and wanted to invite the anesthesiologist and Ed attending to come...

Thanks for all the feedback guys.
 
It doesn't matter if you are the trach master, you should not create a situation for yourself where your plan B is trach.

Plan B trach situations should be those where airway is a disaster and pt is dying from word go.

This pt was breathing spontaneously with his tongue preparing for complete obstruction, so he was in trouble but not a disaster. RSI turned it into a disaster
 
excalibur said:
It doesn't matter if you are the trach master, you should not create a situation for yourself where your plan B is trach.

Plan B trach situations should be those where airway is a disaster and pt is dying from word go.

This pt was breathing spontaneously with his tongue preparing for complete obstruction, so he was in trouble but not a disaster. RSI turned it into a disaster
Click to expand...

Totally agree. Like I said. My eyes nearly popped out when I saw him prop/sux.
 
Stank811 said:
It is always hard judging decisions in complicated clinical situations but I agree this sounds like an attempt at awake FOI or awake trach....and in the event that the decision was made to induce and paralyze I would without question have a cric kit sitting close or even better ENT/general surgery at bedside. "Tongue protruding and drooling" and the words induction would make me really nervous and would want plan B,C,D seconds away.
Click to expand...

Shouldn't it be routine if you are paralyzing someone for intubation to have a cric kit at the bedside and plan B,C,D ready?
 
joeDO2 said:
Shouldn't it be routine if you are paralyzing someone for intubation to have a cric kit at the bedside and plan B,C,D ready?
Click to expand...

No. It is routine to have an LMA and bougie around near by, a FUNCTIONING ventilator (on the way at least), suction, two tubes of different sizes, two blades of different sizes (make sure light source works first), an oral airway (well two of different sizes), a functioning ambu bag, some means of ETCO2 detection (standard of care), and a functioning oxygen source. Ive seen bad crap happen to inexperienced ill prepared nervous physicians by not having any one or combo of the above.

I do not "routinely" have a cric kit laying around.
 
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Let's not forget the 3cc syringe, 18G angiocath and the tube connector to a 7.0 tube + jet ventilator/ambu bag.... :idea:


jet002.jpg
 
You know it... if you are going that far, you are def. gonna have some sphincteritis later that day 😀

I've seen it work though... and it works well. You just need to generate 50 psi to ventilate effectively (20psi for pediatric). O2 tubing ain't gonna cut it (Drager O2 flush valve works, some other OR ventilators won't).

If someone doesn't have the balls to bust out the #11 blade, then this is def. an easy temporizing alternative. You get some Macgyver points using a 3cc syringe.

We have one in our central corridor collecting dust... hasn't been used in a looooong time though. I play with it once or twice a year.
 
I had the 11 blade out, bougie in my pocket. 6.0 ready to stuff in over the bougie.

Surgeon had a wry smile, knowing I've been preparing and waiting for a cric to come my way, and asked me after how much longer I was going to wait for him before I busted the blade out. I said 60 seconds as sats were starting to drop. He laughed and said next time. Then gave me a few cric pointers.

Was a good case to be a part of. Mainly to file in the "do not ever do what the attending did if/when faced with this case again" part of my brain.
 
Should have never sacrificed spontaneous ventilation in this patient. Lose muscle tone on an edematous airway and it can lead to catastrophe in a multitude of ways- spontaneous ventilation, collapse of soft tissues, etc.
 
Not sure. He came up on 4L with a sat of 94-95. When I was called in because his dyspnea was worsening he was like 89-90.the 99% on 2L was what was recorded in Ed vitals. Was 94-95 on first MICU flow sheet set of vitals
 
Bostonredsox said:
Not sure. He came up on 4L with a sat of 94-95. When I was called in because his dyspnea was worsening he was like 89-90
Click to expand...

I've admitted lots of people to babysit for angioedema who didn't need tubed, but any requirement of oxygen should have been big neon sign screaming please think about tubing me,
 
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