OB case

[numbmd]

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I had an interesting OB case a while back.

I'm working the OB Shift, and I'm walking out of a labor room, just after an epi, and I see a huge mass of people flying down the hallway on a stretcher. Right into one of the ORs. I naturally follow cause I know it can't be good. I see a four hundred plus whale lying on the stretcher, with one of the OB residents with their hand up her hoo-ha. I hear someone shouting that we have a cord prolapse and we need to crash the patient. So we cut off her shirt and bra (whoa.. Each breast is like 45 lbs each) and I start trying to look for a vein. Pt was visiting from Ga. and we have no prenatal records. The arm is like a giant doughy cone that starts at two feet wide, then goes down to a wrist. Well anyways I feel this one thing, could be a vein, could be a tendon. As I try I insist that they check the FHR, hoping that it is either up or gone. No luck, 70 bpm on the U/S. My luck gets worse as the tendon is actually a vein, and I get the IV. SH * T!

Now I'm preoxygenating her while I ask a few questions. She ate three hours ago. Oh, and by the way she was recently told by her medical doctor that she has "some problem with her heartbeat."

So this is what I have....
1. one giant pachyderm with a dying baby inside. Can I call a large animal Veterinarian instead?

2. A Jack-O-Lantern for a head on top of two giant boobs on top of the largest belly outside the bariatric room. WTF??? One G-D sh*tty airway. All I see is tongue.

3. some unknown arrythmia.

4. Supine O2 sats on 100% mask....93. No time to put in reverse trend and properly preoxygenate.

What would you do?

 

[Planktonmd]

I had an interesting OB case a while back.

I'm working the OB Shift, and I'm walking out of a labor room, just after an epi, and I see a huge mass of people flying down the hallway on a stretcher. Right into one of the ORs. I naturally follow cause I know it can't be good. I see a four hundred plus whale lying on the stretcher, with one of the OB residents with their hand up her hoo-ha. I hear someone shouting that we have a cord prolapse and we need to crash the patient. So we cut off her shirt and bra (whoa.. Each breast is like 45 lbs each) and I start trying to look for a vein. Pt was visiting from Ga. and we have no prenatal records. The arm is like a giant doughy cone that starts at two feet wide, then goes down to a wrist. Well anyways I feel this one thing, could be a vein, could be a tendon. As I try I insist that they check the FHR, hoping that it is either up or gone. No luck, 70 bpm on the U/S. My luck gets worse as the tendon is actually a vein, and I get the IV. SH * T!

Now I'm preoxygenating her while I ask a few questions. She ate three hours ago. Oh, and by the way she was recently told by her medical doctor that she has "some problem with her heartbeat."

So this is what I have....
1. one giant pachyderm with a dying baby inside. Can I call a large animal Veterinarian instead?

2. A Jack-O-Lantern for a head on top of two giant boobs on top of the largest belly outside the bariatric room. WTF??? One G-D sh*tty airway. All I see is tongue.

3. some unknown arrythmia.

4. Supine O2 sats on 100% mask....93. No time to put in reverse trend and properly preoxygenate.

What would you do?

If the airway is as bad as you said ( Can only see tongue) and the woman is hypoxic initially (SPO2 = 93% on 100% FIO2), then no matter what you do don't put her to sleep until you secure the airway.
If it takes a few more minutes so be it, if they want to start under local that's fine too.
Your approach to the airway would deppend on your level of experience and the equipment available to you.
The ideal would be topical anesthesia then an awake fiberoptic, but you can also do other things like take an awake look with DL after topical anesthesia.
If you have a Glidescope then this is an ideal place to do an awake look with the Glidescope.
Just don't put her to sleep until you secure the airway.
Even if you lose the baby you still have a living Mom.

 

[Noyac]

Plank is absolutely right.

What would I do? I hope I would do what plank just described but.....

Honestly, I have never (at least not as long as I can remember) had severe difficulty putting a tube in an obese pt. I find that they are easier than expected just about every time, especially the females cause the neck is not usually as firm as males. Big MAC 4 blade and get the soft stuff out of the way.

Options:
1) topicalize the airway and take a look or do FOB. This may very well kill the baby or permanently disable it.

2) sit her up and do a spinal.😱 Its possible and maybe your best shot.

3) tell the OB's to do the c/s under local. Never gonna happen. and the baby will be dead

4) call a surgeon or ENT and have the neck prepped for a trach/cric. Proceed with GA.

 

[numbmd]

I couldn't do a spinal, at least sitting, there was a resident with her hand up the vagina. Anything longer than 5 minutes may kill the baby. So no to fiberoptic, local, or spinal in the lateral position.

I told her that this was really going to hurt. Open your mouth and say ahh. I had a few people on each arm and had them prep the belly. Laryngeal grade 2, popped the tube in. Hooked her up, no CO2, sats dropping into the low 70's. Needless to say, I was now the one with rectal pressure and ready to push. "But I saw the tube go in" I'm thinking to myself. Just before I really crap myself, I saw just a smidge of end tidal. Whew! I really thought I was going to kill her.

Lessons I learned:

1. Fat people can really suck as patients.
2. What kind of idiot travels when they are 37 weeks pregnant?
3. Don't forget awake intubations.
4. Even non asthmatics can have wicked bronchospasm.
5. Anesthesia is still a ballsy field. I love my job.

 

[gas87]

Since you brought it up . . . obviously not the main concern in a crashing patient, but:
Has anyone ever sliced through a tendon with an IV or other invasive procedure? Seems like it would be a pretty big complication, needing an extensive ortho repair, but I haven't read anything about
it. Seems like it might be more of a worry in peds than in adults - in neonates with the tiny tendons, and in chubby toddlers especially.

 

[fastosprintini]

hope i don't jinx myself, whenever they call me to OB i take the old bullard scope with me , have to remember to warm it up but i find it makes the difficult airway easy (famous last words🙄)
fasto

 

[VentdependenT]

I had an interesting OB case a while back.

I'm working the OB Shift, and I'm walking out of a labor room, just after an epi, and I see a huge mass of people flying down the hallway on a stretcher. Right into one of the ORs. I naturally follow cause I know it can't be good. I see a four hundred plus whale lying on the stretcher, with one of the OB residents with their hand up her hoo-ha. I hear someone shouting that we have a cord prolapse and we need to crash the patient. So we cut off her shirt and bra (whoa.. Each breast is like 45 lbs each) and I start trying to look for a vein. Pt was visiting from Ga. and we have no prenatal records. The arm is like a giant doughy cone that starts at two feet wide, then goes down to a wrist. Well anyways I feel this one thing, could be a vein, could be a tendon. As I try I insist that they check the FHR, hoping that it is either up or gone. No luck, 70 bpm on the U/S. My luck gets worse as the tendon is actually a vein, and I get the IV. SH * T!

Now I'm preoxygenating her while I ask a few questions. She ate three hours ago. Oh, and by the way she was recently told by her medical doctor that she has "some problem with her heartbeat."

So this is what I have....
1. one giant pachyderm with a dying baby inside. Can I call a large animal Veterinarian instead?

2. A Jack-O-Lantern for a head on top of two giant boobs on top of the largest belly outside the bariatric room. WTF??? One G-D sh*tty airway. All I see is tongue.

3. some unknown arrythmia.

4. Supine O2 sats on 100% mask....93. No time to put in reverse trend and properly preoxygenate.

What would you do?

Strong work man. Hay-zeus Christoh that SUCKS!

 

[Arch Guillotti]

Great case. This is the ultimate rock and a hard place. You are damned if you do and damned if you don't. I have heard tale from an attending in a similar type of circumstance that he had done the same thing before and that it took multiple people to hold this woman down while he tubed her. Taking an awake look was the way to go. Seems like there could be some problems with this though, principally getting the blade in far enough without the pt. gagging and biting down and vomiting all ovet the place. Am curious if you considered a quick spray of hurricane. Seems like that might help things out a bit.

 

[joshmir]

1) In this situation, what is the downside to giving her ketamine (even IM if you can't get an IV) and then doing yor DL?

2) is ketamine, followed by an intubating LMA, a viable option?

3) an attending told me that he has put in large nasal airways and hooked up the circuit to the nasal airway, and squeezed the bag, when he couldn't mask, and this has allowed him to ventilte...has anyone tried this?

 

[numbmd]

Two problems with the ketamine route from my point of view.

1. I would be afraid I might not give enough and just really piss her off. (wondering about dosages in the extremes of weight)

3. A full stomach.

 

[coprolalia]

What was #2?

I've tubed more than a few fatties (who I couldn't figure out how they got pregnant in the first place) and never had a problem, even a beached whale that developed an inadequate spinal midway through the section. Seems that the surgeons hadn't accounted for all that extra blubber in getting to the baby.

Knock on wood, I've yet to have a catastrophe. Even purportedly "scary" patients, like this one, have turned out okay.

-copro

 

[Laurel123]

Seriously though, how do these gigantic women get pregnant - I mean it just doesnt seem technically possible. Anyways, great case. I do think a little bit of ketamine might be helpful - but sometimes in the heat of the moment, that is not a priority. I have seen this done with just 'push and pray' and then after induction, intubation not possible. So it was done with one of those LMAs with the suction ports and miraculously no vomiting and everything OK. But I prefer your approach

 

[leaverus]

Seriously though, how do these gigantic women get pregnant - I mean it just doesnt seem technically possible.

Please don't ask that question ever again. The images it invokes are not palatable.

 

[cchoukal]

1)

3) an attending told me that he has put in large nasal airways and hooked up the circuit to the nasal airway, and squeezed the bag, when he couldn't mask, and this has allowed him to ventilte...has anyone tried this?

an attending made me try this once. worked well, but it doesn't get you around the whole aspiration thing...

 

[Gern Blansten]

Please don't ask that question ever again. The images it invokes are not palatable.

This was discussed in detail in a thread not too long ago. I think it was Vent who knew a little bit too much about the dinner table technique that I mentioned.🙂 Maybe someone can find that thread for you.

Sorry, meant to quote Laurel

 

[joshmir]

how about ketamine then glidescope?

if these fail, coul you just continue to give ketamine throughout and assist spont ventilation?

 

[numbmd]

how about ketamine then glidescope?

if these fail, coul you just continue to give ketamine throughout and assist spont ventilation?

Might work. But you have a belly full of poorly chewed mac and cheese basically staring right at you with only an overworked esophagus in between.

Didn't have a glidescope at the time. Now we have one upstairs at all times.

 

[VentdependenT]

Might work. But you have a belly full of poorly chewed mac and cheese basically staring right at you with only an overworked esophagus in between.

Didn't have a glidescope at the time. Now we have one upstairs at all times.

Glidescope is a cool device. However I have found (again, in my limited experience with it) it leaves little room to manuver the tube into place. A bougie may be the glidescope's best friend.

 

[coprolalia]

Glidescope is a cool device. However I have found (again, in my limited experience with it) it leaves little room to manuver the tube into place. A bougie may be the glidescope's best friend.

You are using a stylet and bending the distal 5-6 cms of the tube at about an 80 degree angle, right? (The classic "hockeystick" configuration.)

-copro

 

[VentdependenT]

You are using a stylet and bending the distal 5-6 cms of the tube at about an 80 degree angle, right? (The classic "hockeystick" configuration.)

-copro

Yes. But because I don't have to crank the head and finger open the jaw I find myself stuffing tube past tongue and soft tissue and eventually have the tube itself blocking my view.

 

[coprolalia]

Yes. But because I don't have to crank the head and finger open the jaw I find myself stuffing tube past tongue and soft tissue and eventually have the tube itself blocking my view.

Huh. Are you still lifting up and away?

I've probably done 2 dozen Glidescope intubations so far (clearly not an "expert" per se) on mostly predicted difficult airways, and one in the ED in a "can't intubate" situation, and I've never had this problem. I've used both the large disposable and the small disposable handles, and they seem to me to be interchangeable. I find that probably the smaller handle will suffice in most instances unless someone is really deep. Usually if you just finagle it a little, the tube drops into view. Just never had a problem using this thing yet, even on what would probably otherwise be an "unintubateable" patient, or at least presents that way (large tongue, MP4, short neck, etc.).

-copro