Nightmare Case

[docB]

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I had an ultramorbidly obese woman come in with angioedema. No IV access despite multiple attempts. Patient was unable to swallow secretions but had a good sat by nasal breathing. I gave everything I could IM, decadron, benadryl, epi. Pt was still getting worse. In reality nothing was going IM, it was all just going into the adipose.

Femorals were impossible due to the massive pannus and the chronic intertriginous yeasty cellulitis. I tried IJ then subclavian (we don’t have ultrasound) then back to IJ where I finally got a line. I couldn’t really feel her clavicle because of the fat. It was dangerous all round. The pt was yelling at me the whole time and moving around but I couldn’t sedate her because her airway/respiratory status was already bad. I prepped for a difficult airway and did RSI with sux and etomidate. Luckily whe had no teeth but I still couldn’t see anything because of the severe edema superimposed over the massive neck and poor landmarks. I tried everything. Every blade, bougie, BURP. We don’t have a bronchoscope. I tried using the laryngoscope pulling one way and the suction pulling the other and still couldn’t see. I hit her with a second dose of etomidate but it didn’t work well. I found out later that the central line which was snaking through about 5 inches of adipose had pulled back and the proximal ports were out of the vein. The saving grace was that I was always able to bag her and her sat stayed above 90 the whole time. I gave another dose of sux and etomidate through the distal port and put her down again. I was stuck. I couldn’t intubate and though I could ventilate the pt had worsening, refractory angioedema and I had to get a definitive airway. So I did a needle cric, ran a wire and did a retrograde intubation which worked really well. I eventually got an IJ on the other side and pulled the tempermental line. What a nightmare. I was very happy with how the retrograde tube went and the pt was stable after all that which made me happy as well.

 

[WakeMedHeel]

Yuck. Nice work though.

 

[leviathan]

I had to actually search for the carotid artery on this 500lb-ish guy last week because he had no neck. Gotta love North America! Congrats on the woman though; sounds like you pulled it off in the end.

 

[leviathan]

I'm not sure, but this might be that patient's no-neck son. You can see he's finished his supersized fries and he is now demanding more food with his index finger.

 

[DrQuinn]

I had an ultramorbidly obese woman come in with angioedema. No IV access despite multiple attempts. Patient was unable to swallow secretions but had a good sat by nasal breathing. I gave everything I could IM, decadron, benadryl, epi. Pt was still getting worse. In reality nothing was going IM, it was all just going into the adipose.

Femorals were impossible due to the massive pannus and the chronic intertriginous yeasty cellulitis. I tried IJ then subclavian (we don’t have ultrasound) then back to IJ where I finally got a line. I couldn’t really feel her clavicle because of the fat. It was dangerous all round. The pt was yelling at me the whole time and moving around but I couldn’t sedate her because her airway/respiratory status was already bad. I prepped for a difficult airway and did RSI with sux and etomidate. Luckily whe had no teeth but I still couldn’t see anything because of the severe edema superimposed over the massive neck and poor landmarks. I tried everything. Every blade, bougie, BURP. We don’t have a bronchoscope. I tried using the laryngoscope pulling one way and the suction pulling the other and still couldn’t see. I hit her with a second dose of etomidate but it didn’t work well. I found out later that the central line which was snaking through about 5 inches of adipose had pulled back and the proximal ports were out of the vein. The saving grace was that I was always able to bag her and her sat stayed above 90 the whole time. I gave another dose of sux and etomidate through the distal port and put her down again. I was stuck. I couldn’t intubate and though I could ventilate the pt had worsening, refractory angioedema and I had to get a definitive airway. So I did a needle cric, ran a wire and did a retrograde intubation which worked really well. I eventually got an IJ on the other side and pulled the tempermental line. What a nightmare. I was very happy with how the retrograde tube went and the pt was stable after all that which made me happy as well.

damn. what a nightmare! You should let your med director know about it... you need some rescue devices. LMA? Intubating LMA? Yucky-poo-poo! I bet the other ED doc working was just glad he wasn't assigned the patient! Glad things turnd out ok, though.... I'd rather have two dissecting hoses than one of your patients.

Q

 

[margaritaboy]

Nice work. Especially with the central line. It takes some balls to do an IJ on a super fat lady without ultrasound. What sort of wire did you use for the retrograde intubation?

Also, any fiberoptic scopes in your ED that you could have used in a pinch?

 

[Dimoak]

I had an ultramorbidly obese woman come in with angioedema. No IV access despite multiple attempts. Patient was unable to swallow secretions but had a good sat by nasal breathing. I gave everything I could IM, decadron, benadryl, epi. Pt was still getting worse. In reality nothing was going IM, it was all just going into the adipose.

Femorals were impossible due to the massive pannus and the chronic intertriginous yeasty cellulitis. I tried IJ then subclavian (we don’t have ultrasound) then back to IJ where I finally got a line. I couldn’t really feel her clavicle because of the fat. It was dangerous all round. The pt was yelling at me the whole time and moving around but I couldn’t sedate her because her airway/respiratory status was already bad. I prepped for a difficult airway and did RSI with sux and etomidate. Luckily whe had no teeth but I still couldn’t see anything because of the severe edema superimposed over the massive neck and poor landmarks. I tried everything. Every blade, bougie, BURP. We don’t have a bronchoscope. I tried using the laryngoscope pulling one way and the suction pulling the other and still couldn’t see. I hit her with a second dose of etomidate but it didn’t work well. I found out later that the central line which was snaking through about 5 inches of adipose had pulled back and the proximal ports were out of the vein. The saving grace was that I was always able to bag her and her sat stayed above 90 the whole time. I gave another dose of sux and etomidate through the distal port and put her down again. I was stuck. I couldn’t intubate and though I could ventilate the pt had worsening, refractory angioedema and I had to get a definitive airway. So I did a needle cric, ran a wire and did a retrograde intubation which worked really well. I eventually got an IJ on the other side and pulled the tempermental line. What a nightmare. I was very happy with how the retrograde tube went and the pt was stable after all that which made me happy as well.

Yeah, wow, definitely sounds like a great job! I agree that you should probably talk to the med director about getting Ultrasound into the ER. Running an IJ blind definitely sounds like a super-gutsy move, it's awesome how you pulled it off. Are you gonna write-up your techniques? With the numbers of morbidly obese people, I'd imagine many more docs will have some difficult lines to run! Thanks for sharing the experience. 🙂

 

[Apollyon]

What sort of wire did you use for the retrograde intubation?

Wow - that's scary bad. I remember another fatty that you mentioned that had an INR of 17. I guess you're "just lucky" when it comes to unexploded bombs!! My pucker factor would have been up there.

As for the wire, I thought you can use the wire out of a central line kit - just in through the hole, don't force it, and watch for it to come out of the mouth. Then again, the last time I did it was never.

 

[FoughtFyr]

Wow - that's scary bad. I remember another fatty that you mentioned that had an INR of 17. I guess you're "just lucky" when it comes to unexploded bombs!! My pucker factor would have been up there.

As for the wire, I thought you can use the wire out of a central line kit - just in through the hole, don't force it, and watch for it to come out of the mouth. Then again, the last time I did it was never.

You cant use the central line wire. It is not generally long enough (think about it, the tube is generally ~30 cm and the wire has to be long enough to stick out of the end). There are retrograde intubation wires and kits.

- H

 

[ERMudPhud]

As for the wire, I thought you can use the wire out of a central line kit - just in through the hole, don't force it, and watch for it to come out of the mouth. Then again, the last time I did it was never.

You can use a central line wire. The other advantage of the wire is that you can use it a landmark if you have to dissect down through a lot of fat and/or angioedema to put in a cric.

DocB and I must have a psychic connection. I spent part of last night trying to do a fiberoptic intubation on a 600 pound guy whose only sedation was his pC02 >100. In the end we got access and the primary ED doc on the case said the hell with it and just put him down with succ's and got the tube via bougie on the first try.

My really scary case from last night though was a 50 yo asthmatic complaining of worsening SOB for 10 days. Totally normal vitals, normal EKG, and no chest pain. Had a saddle embolism occluding >75% of her total right ventricular outflow. So much for pretest probabillity. I only CT'd her because she also had a syncopal episode earlier in the day associated with worsening SOB.

 

[Apollyon]

You cant use the central line wire. It is not generally long enough (think about it, the tube is generally ~30 cm and the wire has to be long enough to stick out of the end). There are retrograde intubation wires and kits.

- H

Thanks for clarifying. From Roberts and Hedges: "60 cm epidural catheter-needle combination or 80 cm (0.88 mm diameter) spring guidewire (J-tip preferred)"

"A prepackaged alternative is the Cook Retrograde Intubation Set (Cook Critical Care, Bloomington, IN), which also contains a sheath."

Next time I'll need to do more of my due diligence.

 

[ERMudPhud]

You cant use the central line wire. It is not generally long enough (think about it, the tube is generally ~30 cm and the wire has to be long enough to stick out of the end). There are retrograde intubation wires and kits.

- H

I'm pretty sure the wire from our triplelumen kits is more than long enough. The triple lumen is almost as long as an ET tube. Next time I have a wire left over I'll line'em up and see how much is left over. If I had to actually search through the ED for a "retrograde kit" I'm pretty sure the patient would be dead before I could find it.

 

[FoughtFyr]

I'm pretty sure the wire from our triplelumen kits is more than long enough. The triple lumen is almost as long as an ET tube. Next time I have a wire left over I'll line'em up and see how much is left over. If I had to actually search through the ED for a "retrograde kit" I'm pretty sure the patient would be dead before I could find it.

I've tried it in the cadaver lab with a long central line wire (the short ones won't work) "head to head" against the kit. It wasn't even close. The central line wire was a b***h to use, too flimsy to keep the tube from "hanging up" on the cords. The kit wire worked smooth (as far as "smooth" can be in this setting). We now have the kits in our airway carts. That said, what did surprise me was how long the procedure took - start to finish. It is not all that easy nor quick, regardless of the wire used.

- H

 

[ERMudPhud]

Our central line kits have a 60cm wire which out to be long enough but I agree probably on the flimsy side. I have to look next time and see if we have a retrograde kit in our airway cart. I don't remember seeing it.

 

[BKN]

Our central line kits have a 60cm wire which out to be long enough but I agree probably on the flimsy side. I have to look next time and see if we have a retrograde kit in our airway cart. I don't remember seeing it.

Every place should have a "difficult airway" cart with bougies, LMAs, perc cric kits, retrograde kit (maybe). And I said it before, there's a videolaryngoscope in your future.

 

[FoughtFyr]

Every place should have a "difficult airway" cart with bougies, LMAs, perc cric kits, retrograde kit (maybe). And I said it before, there's a videolaryngoscope in your future.

I've used the glidescope. It takes practice but works well.

- H

 

[docB]

We don't have a bronchoscope. We will be getting ultrasound. I think it's supposed to be in the 2008 capital budget (not kidding, gotta love private hospitals). We have a difficult airway kit with LMAs (although it doesn't have intubating LMAs), bougies, a combitube and a relatively useless cric kit. Used a retrograde kit that had a thicker, longer guidewire and a stiffer plactic dilator that you shove over the wire to help with the tube placement. It worked really well.

Shooting at the blind IJ was tricky but that's how I was taught. We had limited US availability in my residency (it's better there now). You hold your finger on the carotid and go lateral to your finger aiming at the ipsilateral nipple. For some reason I am better at IJs than subclavians. Actually I did call the radiologist to see if he could come over with an US to guide me on this one. Since that's an unusual occurance at my hospital it took me a while to explain what I wanted and justify it to him. He said OK and 10 minutes later the tech showed up to take the unstable, no airway patient to radiology for the procedure. I was in the middle of trying to tube her so I did't even bother to explain whay that was unacceptable.

 

[AmoryBlaine]

You can use a central line wire. The other advantage of the wire is that you can use it a landmark if you have to dissect down through a lot of fat and/or angioedema to put in a cric.

DocB and I must have a psychic connection. I spent part of last night trying to do a fiberoptic intubation on a 600 pound guy whose only sedation was his pC02 >100. In the end we got access and the primary ED doc on the case said the hell with it and just put him down with succ's and got the tube via bougie on the first try.

My really scary case from last night though was a 50 yo asthmatic complaining of worsening SOB for 10 days. Totally normal vitals, normal EKG, and no chest pain. Had a saddle embolism occluding >75% of her total right ventricular outflow. So much for pretest probabillity. I only CT'd her because she also had a syncopal episode earlier in the day associated with worsening SOB.

ha ha ha ha ha ha.

 

[dcolon_et06]

I'm not sure, but this might be that patient's no-neck son. You can see he's finished his supersized fries and he is now demanding more food with his index finger.

Wow haha. Shave that kids head, paint his entire body white, and he could serve as the Michelin Man's son 😛.

 

[lattimer13]

I had an ultramorbidly obese woman come in with angioedema. No IV access despite multiple attempts. Patient was unable to swallow secretions but had a good sat by nasal breathing. I gave everything I could IM, decadron, benadryl, epi. Pt was still getting worse. In reality nothing was going IM, it was all just going into the adipose.

Femorals were impossible due to the massive pannus and the chronic intertriginous yeasty cellulitis. I tried IJ then subclavian (we don't have ultrasound) then back to IJ where I finally got a line. I couldn't really feel her clavicle because of the fat. It was dangerous all round. The pt was yelling at me the whole time and moving around but I couldn't sedate her because her airway/respiratory status was already bad. I prepped for a difficult airway and did RSI with sux and etomidate. Luckily whe had no teeth but I still couldn't see anything because of the severe edema superimposed over the massive neck and poor landmarks. I tried everything. Every blade, bougie, BURP. We don't have a bronchoscope. I tried using the laryngoscope pulling one way and the suction pulling the other and still couldn't see. I hit her with a second dose of etomidate but it didn't work well. I found out later that the central line which was snaking through about 5 inches of adipose had pulled back and the proximal ports were out of the vein. The saving grace was that I was always able to bag her and her sat stayed above 90 the whole time. I gave another dose of sux and etomidate through the distal port and put her down again. I was stuck. I couldn't intubate and though I could ventilate the pt had worsening, refractory angioedema and I had to get a definitive airway. So I did a needle cric, ran a wire and did a retrograde intubation which worked really well. I eventually got an IJ on the other side and pulled the tempermental line. What a nightmare. I was very happy with how the retrograde tube went and the pt was stable after all that which made me happy as well.

strong work man. that's the best when you're trying to do something (as in this case saving the fatty's life) and the patient is yelling at you. ungrateful and ingnorant bastards.

 

[DropkickMurphy]

I had an ultramorbidly obese woman come in with angioedema. No IV access despite multiple attempts. Patient was unable to swallow secretions but had a good sat by nasal breathing. I gave everything I could IM, decadron, benadryl, epi. Pt was still getting worse. In reality nothing was going IM, it was all just going into the adipose.

Femorals were impossible due to the massive pannus and the chronic intertriginous yeasty cellulitis. I tried IJ then subclavian (we don’t have ultrasound) then back to IJ where I finally got a line. I couldn’t really feel her clavicle because of the fat. It was dangerous all round. The pt was yelling at me the whole time and moving around but I couldn’t sedate her because her airway/respiratory status was already bad. I prepped for a difficult airway and did RSI with sux and etomidate. Luckily whe had no teeth but I still couldn’t see anything because of the severe edema superimposed over the massive neck and poor landmarks. I tried everything. Every blade, bougie, BURP. We don’t have a bronchoscope. I tried using the laryngoscope pulling one way and the suction pulling the other and still couldn’t see. I hit her with a second dose of etomidate but it didn’t work well. I found out later that the central line which was snaking through about 5 inches of adipose had pulled back and the proximal ports were out of the vein. The saving grace was that I was always able to bag her and her sat stayed above 90 the whole time. I gave another dose of sux and etomidate through the distal port and put her down again. I was stuck. I couldn’t intubate and though I could ventilate the pt had worsening, refractory angioedema and I had to get a definitive airway. So I did a needle cric, ran a wire and did a retrograde intubation which worked really well. I eventually got an IJ on the other side and pulled the tempermental line. What a nightmare. I was very happy with how the retrograde tube went and the pt was stable after all that which made me happy as well.

DocB, this is just one more reason I respect you. Nice work! 👍

 

[GeneralVeers]

strong work man. that's the best when you're trying to do something (as in this case saving the fatty's life) and the patient is yelling at you. ungrateful and ingnorant bastards.

I always find that the biggest, fattest patients who are in respiratory distress tend to be the most belligerent. They're the ones who scream and hit the nurses when they try the intial (but futile IV), and make any "sterile" procedure near impossible. I had a 500 lb guy in CHF a couple of months ago, cursing and swearing whenever anyone would try to help him.

 

[DropkickMurphy]

I'm not sure, but this might be that patient's no-neck son. You can see he's finished his supersized fries and he is now demanding more food with his index finger.

That's his finger? I thought he was holding a bratwurst..... Cases like that should be grounds for removing the kid from the parents' custody.... 😡

 

[GeneralVeers]

That's his finger? I thought he was holding a bratwurst..... Cases like that should be grounds for removing the kid from the parents' custody.... 😡

You notice how the other kid is fat too? One could definitely make the case for child abuse.

 

[DropkickMurphy]

You notice how the other kid is fat too? One could definitely make the case for child abuse.

Yeah, precisely......

 

[Miami_med]

You notice how the other kid is fat too? One could definitely make the case for child abuse.

Or a familial hypothyroidism.

 

[GeneralVeers]

Or a familial hypothyroidism.

Sure, just like every other obese person who blames it on "genes". Which is more likely?

 

[bartleby]

If you don't have ultrasound and you can't palpate the carotid due to adipose tissue, you can always use a doppler to find it. Then go lateral to your mark aiming towards the ipsilateral nipple.

When you have someone with dyspnea who mentions (usually as an aside) that they had either pre-syncope or syncope, consider this an attempt by the Fates to throw you a bone before you find yourself in M&M squeaking, "But he didn't have pleuritic chest pain!" after you learn about another pulmonary embolus diagnosed by autopsy.

 

[lattimer13]

Sure, just like every other obese person who blames it on "genes". Which is more likely?

👍 seriously

 

[deleted6669]

did you consider IO access after a little local? with the new ez io's you can get an io in essentially anyone in about 15 seconds.
benadryl, pepcid, solumedrol, even an epi drip can go through an IO.....
nice job on the needle crich airway conversion to retrograde intubation.

 

[docB]

Got a question PMd to me that may generate some interesting discussion:

Question: "That does sound like a nightmare. At least the positive outcome gets you a good story!
Out of curiosity, I always imagined that it's pretty difficult to find the landmarks for a cric on such an obese patient right? Is there a trick or strategy to it?"

docB: "It can be pretty tough. I was lucky on this one (within the overwhelmingly unlucky situation). I was able to palpate the trachea and the knob. I found the cric just south where I expected it. It's easier to get a needle into something while you're pressing down the flab with your fingers than it is to get a blade in. So it's fortunate that I was doing a needle cric rather than a full cric.

That's a good question. Do you mind if I paste it onto the actual thread?"

Question: "Sure go ahead and post it.
Your answer makes me think of another question. So in the case of an obese patient, would a needle cric be a lot easier than a surgical cric? I guess I'm imaginging that a scalpel cut through the fat with a vertical incision, would allow you to get in there and feel things out a little better. But that's just imagination 🙂 (I'm only an M1--and a paramedic--and just wondering what the heck my best options would be...)"

docB: "Another good question. It might be easier to do a needle cric on an obese patient. I didn't do it in this case because I wasn't at the full "can't intubate, can't ventilate" situation and I didn't feel a full cric was warrented yet."

 

[docB]

did you consider IO access after a little local? with the new ez io's you can get an io in essentially anyone in about 15 seconds.
benadryl, pepcid, solumedrol, even an epi drip can go through an IO.....
nice job on the needle crich airway conversion to retrograde intubation.

You know I didn't consider it. Afterward I wished that we had one of the new sternal IO setups but we don't. I agree that in the future some type of IO will be the go to modality in that situation.

 

[beyond all hope]

Obviously not when you're trying to get an airway on Fatty McFattypants, but maybe when you see a four year old that weighs sixty kg.

However, I have noticed that many undereducated families think that their morbidly obese children are 'good eaters' and 'growing well'. After all, obese children look happy. I think there is a real lack of insight in many cases, not just denial or lack of discipline.

I have sat down with them and tried to educate the parents. Some of them truly don't understand what a burden they are putting on their children.

 

[DropkickMurphy]

Our central line kits have a 60cm wire which out to be long enough but I agree probably on the flimsy side. I have to look next time and see if we have a retrograde kit in our airway cart. I don't remember seeing it.

Our A-line kits we used at the last ICU I worked in had a rather sturdy and quite long (I never looked to see precisely how long) guidewire that might work in such a kit. I also know we stocked them in the ER, but they also stocked the Cook retrograde kits, but if they had not, my first call would be to grab one of the A-line kits for the wire out of it.

 

[BKN]

Got a question PMd to me that may generate some interesting discussion:


.
Your answer makes me think of another question. So in the case of an obese patient, would a needle cric be a lot easier than a surgical cric? I guess I'm imaginging that a scalpel cut through the fat with a vertical incision, would allow you to get in there and feel things out a little better. But that's just imagination 🙂 (I'm only an M1--and a paramedic--and just wondering what the heck my best options would be...)"

."

My experiences with surgical airways in a crash is that they are always big thrashes. Usually ventilation is minimal to absent, Intubation from above has failed and the swelling from trauma or infection that led to the emergency pretty much has destroyed all the surface landmarks. Also, after all of the above, your hands are likely to have a big adrenalin tremor, fine surgical skills are difficult at best.

Literature suggests that the major complication rate is very high (about 40%, think carotid or jugular laceration, failed airway, perforated esophagus with mediastinits later, etc).

In reference to the question above, I have often made the mistake of thinking that if I just get the skin open and can dissect or feel my way to the airway things will get better. Usually things get worse, you get off the midline and get lost in bloody territory.

What you do in this situation can not be dictated except by the situation. But I think, after having had several of these disasters, that if you can pick up the larynx in one hand, make a skin stab incision and use a perc cric kit, you will have the best chance of success.

Anyway, if I never have the situation again, it will be great.😎

 

[allylz]

In reference to the question above, I have often made the mistake of thinking that if I just get the skin open and can dissect or feel my way to the airway things will get better. Usually things get worse, you get off the midline and get lost in bloody territory.

Hello, I am very new to all this and although I have done two rotations in the ED, I have not seen any situations with difficult airways or even any intubations at all. I was in an interview situation with our department chair, and he said "what procedure do EM doctors do that really scares you?" I'm not particularly scared about doing any procedures (probably because I haven't seen enough yet), but I didn't want to talk about something I hadn't seen and knew nothing about. So I said putting in a central line, which I don't think is really that scary, but I saw it being done and it looked fairly difficult in terms of the force that the resident was using to get it to go where he wanted it to (another fat patient) - I have very weak little girly arms. Anyway the chair looked at me funny and said "hmm, central lines usually aren't very hard." and I felt pretty dumb. I didn't want to follow that up by saying "well I really haven't seen much in the way of procedures, in my defense..." cause that just doesn't sound good. I only have the haziest understanding of what you guys are talking about in this thread, but it seems like there is a good answer to this question in here somewhere...

 

[bartleby]

Don't worry...it's all in the wrists.

I have very weak little girly arms....

 

[ERMudPhud]

In reference to the question above, I have often made the mistake of thinking that if I just get the skin open and can dissect or feel my way to the airway things will get better. Usually things get worse, you get off the midline and get lost in bloody territory.

I totally agree with BKN on this one. Once you are through the skin in a fat/edematous person it all turns into a slippery, swollen, bloody mess with no landmarks. Next time if I don't have a perc cric kit I'm doing a needle cric with a wire. If I can use the wire for a retrograde, great. Otherwise I'm leaving it in and using it as a landmark to lead me where I need to go.

 

[emtcsmith]

I think someone already said it but ez-io would work like a dream.