Nice Learning Case

[jetproppilot]

50 year old female in the ER with second degree burns to head and neck...awaiting transfer to burn unit...I got a call (last night, my last night of my night-week) from the ER doctor requesting intubation...says she isnt comfortable intubating this patient.

On arrival, lady is conscious and alert, able to talk, minimal (but some) stridor, significant facial swelling from edema, some neck swelling. Able to talk, follow commands. Patient requesting medicine for "congestion".

"Good call", I think to myself, concerning the ER attendings hesitancy to intubate this lady.

How do I proceed, folks? What do I have with me? What do I avoid? What are my thoughts before I begin? Whats is Plan A, Plan B, and Plan C?

---

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[ThinkFast007]

will need a FOB I'm pretty sure

 

[MAC10]

If she had a good MP score and good mouth opening i would probably feel comfortable doing an rapid sequence with sux (if burn less 24 hrs), propfol and my best blade. I would have a fast track LMA with me and if i couldnt get the intubation plan B would be to ventilate her up with the LMA and then try to fast track or fiberoptic through the LMA.

If the MP and MO looks bad i would probably go with an awake fiberoptic.

 

[jetproppilot]

If she had a good MP score and good mouth opening i would probably feel comfortable doing an rapid sequence with sux (if burn less 24 hrs), propfol and my best blade. I would have a fast track LMA with me and if i couldnt get the intubation plan B would be to ventilate her up with the LMA and then try to fast track or fiberoptic through the LMA.

If the MP and MO looks bad i would probably go with an awake fiberoptic.

Nice post.

Will await several more posts and then I'll divulge my thoughts, concerns, preparations, and action (which worked, but I had backup plans as well).

I think thats an important point to make. If you are afforded the luxury of time to think something out, do so. Arrive at a plan of action. Then plan a secondary plan of action if Plan A is insuccessful, and a PLan C if Plan B is unsuccessful.

This is where anesthesiologists earn their money...tertiary thinking when the chips are down, in a clinical situation where ONE wrong move will result in significant morbidity or death.

In reference to a fast track LMA, I don't think its useful in this environment. Remember the primary concern here is airway edema and distortion...a fast-track's efficacy relies on the ability of the airway to conform around the glottis...which may not happen since tissue extravascation distorts normal anatomy...and even if it accomplishes conforming around the glottis, edematous glottis/cords will prevent airway exchange since said edematous glottis will probably reduce, and may prohibit, air exchange...you can squeeze the ambu-bag as hard as you can, but the air will leak, not able to make it thru the edematous glottis.

 

[VentdependenT]

preoxygenate then AWAKE FIBEROPTIC.

If you put her down and lose that airway you and the patient are toast. Who knows what the hell you are going to see back there once you induce and slip your mac in. Forget it.

Sure you can throw in an LMA to CYA but what happens if the swelling progresses? Buh bye airway.

If you are feeling confident enough to do an asleep fiberoptic then have an ENT dude on hand if you need to cric the patient. She may need it anyways if swelling progresses around the tube and then causes tracheomalacia/tracheal injury.

glyco up front
check her potassium anyhoots, word on what mac said bout sux


Just curious about the cause of the burn? Fire, electical, chemical, smoke inhalation, singed nares (I like saying nares)?

 

[jetproppilot]

preoxygenate then AWAKE FIBEROPTIC.

If you put her down and lose that airway you and the patient are toast. Who knows what the hell you are going to see back there once you induce and slip your mac in. Forget it.

Sure you can throw in an LMA to CYA but what happens if the swelling progresses? Buh bye airway.

If you are feeling confident enough to do an asleep fiberoptic then have an ENT dude on hand if you need to cric the patient. She may need it anyways if swelling progresses around the tube and then causes tracheomalacia/tracheal injury.

glyco up front
check her potassium anyhoots, word on what mac said bout sux


Just curious about the cause of the burn? Fire, electical, chemical, smoke inhalation, singed nares (I like saying nares)?

Another nice post.

Glyco takes about twenty minutes to provide a "drier" intubating environment. I routinely give it plenty ahead of a routine, planned fiberoptic. Didnt think about it while I was chillin' at my crib when I got the phone call. In retrospect, I would've liked to tell the ER MD to give .2 mg glyco immediately, yet another factor optimizing while I drive into the hospital.

I'll think of that next time.

Thanks, Venty.

 

[VentdependenT]

I'll have a extra dirty grey goose martini or two for you and yours tonight jet.

Interested to hear how it went.

 

[Monty Python]

50 year old female in the ER with second degree burns to head and neck...awaiting transfer to burn unit...I got a call (last night, my last night of my night-week) from the ER doctor requesting intubation...says she isnt comfortable intubating this patient.

On arrival, lady is conscious and alert, able to talk, minimal (but some) stridor, significant facial swelling from edema, some neck swelling. Able to talk, follow commands. Patient requesting medicine for "congestion".

"Good call", I think to myself, concerning the ER attendings hesitancy to intubate this lady.

How do I proceed, folks? What do I have with me? What do I avoid? What are my thoughts before I begin? Whats is Plan A, Plan B, and Plan C?

1. consider doing it in the OR, which is your playground with all your toys immediately available, and not on a road trip in the ER. Have your friendly ENT in the OR just in case?

2. have a range of smaller ETTs available. While this pt might normally take a 7.0, you might want to think first attempt with a 5.5 or 6.0. But just have them ready and styletted from the outset.

3. if going awake FOB: precedex infusion, ?? blocks due to edema ?? (probably no), don't bungle the airway - similar philosophy as with epiglottitis.

 

[ThinkFast007]

just a MS4...


i have been personal witness to a pt that had epiglottitis and was tubed by the ER doc in the ER!

bad idea obviously...after a couple esophageal intubations and desaturating to <45% (the pulse ox starts to act kinda funny when the sats are 'low') she got it in w/ a 6.5 on a pretty big male pt.

cuz of this i would have to concur w/ trinity and say...maybe doing this in the OR might not be a bad idea

 

[zippy2u]

You didn't use the FOB. Give her some sedation with versed and fentanyl. Tell her that you'll put the tube in nasally, that way she'll be more comfortable in burn unit. Try for a 7.5 size tube and lubricate it well. Afrin and 4% lido to nasal passages with atomizer. Have Magills, LMA and FOB at hand. Bang her with Prop and sux and place tube within 15 seconds without Magills and without breaking a sweat. Confirm bilat. breath sounds , write a brief note on the chart, wink at the ER doc if she's a hottie and throw the face sheet in the shredder-- what's a couple hundred dollars when your net worth is 7 figures. Regards, ----Zip

 

[jetproppilot]

1. consider doing it in the OR, which is your playground with all your toys immediately available, and not on a road trip in the ER. Have your friendly ENT in the OR just in case?

2. have a range of smaller ETTs available. While this pt might normally take a 7.0, you might want to think first attempt with a 5.5 or 6.0. But just have them ready and styletted from the outset.

3. if going awake FOB: precedex infusion, ?? blocks due to edema ?? (probably no), don't bungle the airway - similar philosophy as with epiglottitis.

AND THE TRIN SPEAKS.

Had a 6.0 styletted next to the 7.0, just in case.

 

[jetproppilot]

You didn't use the FOB. Give her some sedation with versed and fentanyl. Tell her that you'll put the tube in nasally, that way she'll be more comfortable in burn unit. Try for a 7.5 size tube and lubricate it well. Afrin and 4% lido to nasal passages with atomizer. Have Magills, LMA and FOB at hand. Bang her with Prop and sux and place tube within 15 seconds without Magills and without breaking a sweat. Confirm bilat. breath sounds , write a brief note on the chart, wink at the ER doc if she's a hottie and throw the face sheet in the shredder-- what's a couple hundred dollars when your net worth is 7 figures. Regards, ----Zip

SEE WHAT HAPPENS WHEN WE CLOSE THE PROPAGANDA THREADS???

The Zipster comes out of his clandestine hiding place.

Good to see you, and thanks for the Zipster contribution.

 

[Monty Python]

just a MS4...


i have been personal witness to a pt that had epiglottitis and was tubed by the ER doc in the ER!

bad idea obviously...after a couple esophageal intubations and desaturating to <45% (the pulse ox starts to act kinda funny when the sats are 'low') she got it in w/ a 6.5 on a pretty big male pt.

cuz of this i would have to concur w/ trinity and say...maybe doing this in the OR might not be a bad idea

You can pick up any anesthesia textbook and find several major mistakes made in the above case management, unless the patient was on death's doorstep in the ER.

 

[VentdependenT]

You didn't use the FOB. Give her some sedation with versed and fentanyl. Tell her that you'll put the tube in nasally, that way she'll be more comfortable in burn unit. Try for a 7.5 size tube and lubricate it well. Afrin and 4% lido to nasal passages with atomizer. Have Magills, LMA and FOB at hand. Bang her with Prop and sux and place tube within 15 seconds without Magills and without breaking a sweat. Confirm bilat. breath sounds , write a brief note on the chart, wink at the ER doc if she's a hottie and throw the face sheet in the shredder-- what's a couple hundred dollars when your net worth is 7 figures. Regards, ----Zip

Zip, how do you slip that $#tch in without mcgills? I've only done ONE so far but man that little bastard just wouldn't track into the glottis.

oh yes, and the martinies were out of this world tonight.

 

[zippy2u]

Typically, in their intense desire to get tube in, the noobies use too much upward pressure on the laryngoscope causing the tube to head towards the esophagus. Lighten up on the upward pressure and try to use right nare and you should be headed for the glottis. Imagine the blind nasal intubation(no upward pressure because you don't use a laryngoscope) and the ETT usually slips right in the glottis. Regards, ----Zippy

 

[Tenesma]

a cool trick for nasals without mcgill.... w/ a DL bring the tip of the ETT above the cords then have assistant inflate the balloon so that the tip elevates itself off the posterior hypopharynx wall - slowly advance so that the tip of the ETT is just barely past the cords, then have assistant deflate cuff so that you can get it past the cords completely...

 

[militarymd]

Some sort of spontaneous ventilation....propofol or sevo....and then intubate in any way you can....

As for the nasal tube....us ICU guys don't like them...especially if they will be tubed for a while.

There is an association between Naso tubes and VAP and sinusitis....weak association, but we try to do everything we can to prevent tube related complications in patients that overall have a double digit mortality.

 

[Noyac]

Some sort of spontaneous ventilation....propofol or sevo....and then intubate in any way you can....

As for the nasal tube....us ICU guys don't like them...especially if they will be tubed for a while.

There is an association between Naso tubes and VAP and sinusitis....weak association, but we try to do everything we can to prevent tube related complications in patients that overall have a double digit mortality.

I would argue that if they are going to be tubed for an extended period of time ( not likely in this case) then you might as well trach them. More likely in larger surface area burns.

 

[davvid2700]

this sounds like an awake fier optic to me.. Stridor.. potential loss of airway.. if you induce unconsciusness you theoretically can lose the ability to ventilate if you need to so thus favoring the awake options however Im not so sure a rapid sequence induction is totally wrong If you have a good airway and you are confident you can intubate her. (on the boards though if you choose this option you WILL lose the airway and she will regurgitate stomach contents. and there will be no ent to help you out and you will be coming back next year to the next expensive city.) but i dont think its totally wrong option.

I would do an awake fiberoptic through the mouth or nose.. either way..

4 percent lido transtracheally

4 percent lido via atomizer tongue back of tongue

2 second benzocain spray tongue and back of pharynx

put the tube in that way confirm breath sounds and et co2
and provide adequate sedation after intubation.

if you dont have time you can just do an awake intubation with topical anesthesia..

the key in this case is dont abolish spontaneous ventilation because you may not be able to ventilate her

even if you think you can judiciously sedate her.. she can still obstruct and spiral downwards from there..

 

[ThinkFast007]

You can pick up any anesthesia textbook and find several major mistakes made in the above case management, unless the patient was on death's doorstep in the ER.

yup i know...it's supposed to be done in the OR,etc...

 

[Tenesma]

david... what would you tell the oral examiner after they tell you she vomits right after her cords are completely numbed up (transtracheal/posterior pharynx topical)? just curious

 

[stephend7799]

david... what would you tell the oral examiner after they tell you she vomits right after her cords are completely numbed up (transtracheal/posterior pharynx topical)? just curious

head down

suction vigorously


assess if she/he aspirated

if not and regurgitation controlled.. patient in no further distress press on with task that you were performing

if so and patient in distress and in imminent respiratory failure then awake intubation (try to get that tube in immediately) if you fail then trach has to be considered...



thats what i would say

 

[davvid2700]

head down

suction vigorously


assess if she/he aspirated

if not and regurgitation controlled.. patient in no further distress press on with task that you were performing

if so and patient in distress and in imminent respiratory failure then awake intubation (try to get that tube in immediately) if you fail then trach has to be considered...

thats what i would say

ditto..

thats what i say too

 

[Noyac]

david... what would you tell the oral examiner after they tell you she vomits right after her cords are completely numbed up (transtracheal/posterior pharynx topical)? just curious

I would tube her, either by DL or FOB ( depending on respiratory status) and assess via FOB whether she has aspirated or not. If so, suction to clear the aspirate. All of this would be done of course after head down and vigorous suction to clear oral pharynx.

 

[jetproppilot]

50 year old female in the ER with second degree burns to head and neck...awaiting transfer to burn unit...I got a call (last night, my last night of my night-week) from the ER doctor requesting intubation...says she isnt comfortable intubating this patient.

On arrival, lady is conscious and alert, able to talk, minimal (but some) stridor, significant facial swelling from edema, some neck swelling. Able to talk, follow commands. Patient requesting medicine for "congestion".

"Good call", I think to myself, concerning the ER attendings hesitancy to intubate this lady.

How do I proceed, folks? What do I have with me? What do I avoid? What are my thoughts before I begin? Whats is Plan A, Plan B, and Plan C?

Here's how it went:

We have an in-house CRNA, so I called ahead and had her ready everything I wanted to bring...etomidate (propofol wouldda worked too), mivacurium, in case I thought I could paralyze her...sometimes descriptions from ER docs are way overplayed, so I wanted a short acting paralytic...we have an intubation toolbox, so I made sure the Miller 2 (my favorite blade) was shining brightly on arrival...and a jet ventilator setup.

My thoughts on sux: I love the drug. Use it all the time. But not on burns. I know, I know...first 24 hours, and something like 1-2 years after a burn injury, its supposed to be safe. I stay away from it. Just me.

Arrived in the ED, lady looked worse than I envisioned in my head. Her appearance definitely ruled out paralysis. First off, I took my time and found the cricothyroid membrane, then found it again. Took a Sharpie and put a black line where I'd stick the 14" angio if things went awry...I've done it before, and was confident I could do it on this lady. Kinda freaked the ER nurses out...

"DR JET, YOURE GONNA TRACH HER???"

I chuckled, said no, just setting up plan B.

So now down to business. Shoulder roll so I can maximize head extension, both for intubation and potential crich. Wanna give enough etomidate to stun her without causing apnea. Start with 6 mg. She goes down a little, but not enough...mandibular lift makes her squirm....6mg more...about a minute later I'm pulling up on her mandible big time, shes not moving but still breathing. Perfect. Time to take a look.

Miller 2 inserted, lady is still breathing, not objecting much. Glottis with some edema, held the blade there for a few seconds, watched for cords and listened to her breathe...spontaneous breathing patients make it easier to find what you're looking for when anatomy is distorted for whatever reason (like this case, CEA with hematoma, etc), saw what I needed to see, 7.0 styletted tube through...respirations heard through the end of the tube...

bingo.

After verification with ETCO2 thinghy (even though I knew it was in), midazolam 5mg, lady a little hyperdynamic, labetolol 5mg settled her down.

I felt comfortable with this approach, and my back up plans. Would I have handled it this way early in my career? Probably not. Probably wouldda got the ENT dude outta bed for a trip to the OR. But I consider myself a pretty good laryngoscopist, and as long as I dont burn any bridges, I'm gonna take a look. Didnt paralyze her, didnt make her stop breathing, had a backup plan. Good enough for me.

I think anesthesiologists start out in private practice very cautious...probably over cautious...but thats OK...and with more and more cases under your belt, you figure out what you are comfortable with, what you are not...which things your teaching attendings said are important, and which things are not...what you really need for a certain case/scenerio, and what you dont need.

There ya have it.

 

[Noyac]

Here's how it went:

We have an in-house CRNA, so I called ahead and had her ready everything I wanted to bring...etomidate (propofol wouldda worked too), mivacurium, in case I thought I could paralyze her...sometimes descriptions from ER docs are way overplayed, so I wanted a short acting paralytic...we have an intubation toolbox, so I made sure the Miller 2 (my favorite blade) was shining brightly on arrival...and a jet ventilator setup.

My thoughts on sux: I love the drug. Use it all the time. But not on burns. I know, I know...first 24 hours, and something like 1-2 years after a burn injury, its supposed to be safe. I stay away from it. Just me.

Arrived in the ED, lady looked worse than I envisioned in my head. Her appearance definitely ruled out paralysis. First off, I took my time and found the cricothyroid membrane, then found it again. Took a Sharpie and put a black line where I'd stick the 14" angio if things went awry...I've done it before, and was confident I could do it on this lady. Kinda freaked the ER nurses out...

"DR JET, YOURE GONNA TRACH HER???"

I chuckled, said no, just setting up plan B.

So now down to business. Shoulder roll so I can maximize head extension, both for intubation and potential crich. Wanna give enough etomidate to stun her without causing apnea. Start with 6 mg. She goes down a little, but not enough...mandibular lift makes her squirm....6mg more...about a minute later I'm pulling up on her mandible big time, shes not moving but still breathing. Perfect. Time to take a look.

Miller 2 inserted, lady is still breathing, not objecting much. Glottis with some edema, held the blade there for a few seconds, watched for cords and listened to her breathe...spontaneous breathing patients make it easier to find what you're looking for when anatomy is distorted for whatever reason (like this case, CEA with hematoma, etc), saw what I needed to see, 7.0 styletted tube through...respirations heard through the end of the tube...

bingo.

After verification with ETCO2 thinghy (even though I knew it was in), midazolam 5mg, lady a little hyperdynamic, labetolol 5mg settled her down.

I felt comfortable with this approach, and my back up plans. Would I have handled it this way early in my career? Probably not. Probably wouldda got the ENT dude outta bed for a trip to the OR. But I consider myself a pretty good laryngoscopist, and as long as I dont burn any bridges, I'm gonna take a look. Didnt paralyze her, didnt make her stop breathing, had a backup plan. Good enough for me.

I think anesthesiologists start out in private practice very cautious...probably over cautious...but thats OK...and with more and more cases under your belt, you figure out what you are comfortable with, what you are not...which things your teaching attendings said are important, and which things are not...what you really need for a certain case/scenerio, and what you dont need.

There ya have it.

NICE

 

[Danger Man]

Thanks, Jet--brings together a lot of book knowledge and clinical experience.