On call airway

[Skrubz]

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So I was on call in the MICU a couple nights ago...

Around 01:00 we were consulted on a patient in respiratory distress on the floor. Here's the scoop:
25 y/o male w/ neurofibromatosis I, GERD & hx asp PNA, seizures, and mild-mod developmental delay. He has this L neck mass that has tripled in size over the last 3 months (2x2x2 cm => 6x6x6 cm). Per MRI report, it's surrounding his carotid and extends from the jugular foramen down to T3 and medial into the nasopharynx. Involvement of CN X-XII, likely mandibular involvement.

He was seen in anesthesia preop clinic earlier in the day for a neck biopsy to be done tomorrow (now today), noted to be satting mid-80s on RA. Slapped on some O2 and sent to the ED. Originally satting mid-90s on 4L NC and admitted to medicine. Progressive deterioration overnight and by the time we see him, he's mid-90s on a non-rebreather with significant inspiratory stridor. Racemic epi hasn't helped and they're giving him a bolus of Solumedrol as we walk in the room.

He's uncooperative with exam, won't/can't open his mouth and his neck is deviated to the left. Unsure if it's muscular resistance or from the mass. He's huffing and puffing in the mid 30s and has significant inspiratory stridor. No ENT in-house. I'm at the bedside, there's an anesthesia attending in-house on OB (plus another anesthesia resident) and a SICU resident in-house. Addendum: Forgot to add in his ABG... 7.30/68/138 on the NRB. May change your management, may not.

What would you guys do? I'll post what I ended up doing later...

 

[UTSouthwestern]

So I was on call in the MICU a couple nights ago...

Around 01:00 we were consulted on a patient in respiratory distress on the floor. Here's the scoop:
25 y/o male w/ neurofibromatosis I, GERD & hx asp PNA, seizures, and mild-mod developmental delay. He has this L neck mass that has tripled in size over the last 3 months (2x2x2 cm => 6x6x6 cm). Per MRI report, it's surrounding his carotid and extends from the jugular foramen down to T3 and medial into the nasopharynx. Involvement of CN X-XII, likely mandibular involvement.

He was seen in anesthesia preop clinic earlier in the day for a neck biopsy to be done tomorrow (now today), noted to be satting mid-80s on RA. Slapped on some O2 and sent to the ED. Originally satting mid-90s on 4L NC and admitted to medicine. Progressive deterioration overnight and by the time we see him, he's mid-90s on a non-rebreather with significant inspiratory stridor. Racemic epi hasn't helped and they're giving him a bolus of Solumedrol as we walk in the room.

He's uncooperative with exam, won't/can't open his mouth and his neck is deviated to the left. Unsure if it's muscular resistance or from the mass. He's huffing and puffing in the mid 30s and has significant inspiratory stridor. No ENT in-house. I'm at the bedside, there's an anesthesia attending in-house on OB (plus another anesthesia resident) and a SICU resident in-house.

What would you guys do? I'll post what I ended up doing later...

HeliOx baby, HeliOx! Might help a little with this guy's obviously non-laminar airflow pattern.

Seriously though, this is a worst case situation with a patient with an airway likely with the geometry of a pretzel. Two things will keep this man alive: Maintaining his spontaneous respiration and finding an alternate route of ventilation.

Having had this situation before at Parkland, but with ENT available, I have used a 14 gauge angiocath as a temporizing measure hooked to a wall O2 outlet with a stopcock at the hub and the O2 cranked out to max (it will go to the wall pressure of 50 mmHg if you just keep turning it until the regulator can't turn anymore). Was like an instant pop off valve and the patients VS stabilized with sats restored to the high 90's and mentation significantly improved.

Given the largely unknown nature of the mass and the fact that it is growing and likely obstructing the airway, paralyzing the patient in an attempt to get a quick look is likely to expedite his passage to the graveyard, although it's possible you could get an airway through. Without ENT to back you up or if you aren't comfortable traching/cricing somone, you are taking a 50/50 chance at best.

Other temporizing measures include putting the patient on BiPAP 20/10, heliox (not as effective as billed), nasal airway if the obstruction is thought to be higher, a good jaw thrust if the patient hasn't had that yet, retrograde intubation, fiberoptic examination and attempt at intubation with plenty of local and topical neosynephrine.

If the patient is crashing, cut the neck at the cricoid cartilage, bluntly dissect the tissue away with your finger or a clamp, cut the cartilage transversely about 1-2 cm and ram a 6.0 ETT through it.

 

[Noyac]

Nice UT!

Here's my thoughts.
Bring pt to the OR. Have someone skilled in surgical airway available(gen. surg, ENT preferably but not avail). This is a mentally handicapped pt(binging PC here) and will most likely not cooperate especailly in the light of hypoxia and resp. distress. I would sedate somehow, IV glyco and ketamine enough to stun, so as to tolerate sevo mask induction. I would deffinitely do the 14g angio trck UT mentioned. This not only gives you a way to oxygenate but also tells you where the trachea is (deviation can be hard to find in crisis). Get him deep enough to look via DL or just go straight to FOB (probably nasal). While surgery is prepping the neck for surgical airway. KEEP HIM BREATHING!

I may have missed a few things but you get the gist.

UT is right, this is one of the worst airway cases there is. Mentally handicapped and in resp distress from a neck mass.

 

[jetproppilot]

So I was on call in the MICU a couple nights ago...

Around 01:00 we were consulted on a patient in respiratory distress on the floor. Here's the scoop:
25 y/o male w/ neurofibromatosis I, GERD & hx asp PNA, seizures, and mild-mod developmental delay. He has this L neck mass that has tripled in size over the last 3 months (2x2x2 cm => 6x6x6 cm). Per MRI report, it's surrounding his carotid and extends from the jugular foramen down to T3 and medial into the nasopharynx. Involvement of CN X-XII, likely mandibular involvement.

He was seen in anesthesia preop clinic earlier in the day for a neck biopsy to be done tomorrow (now today), noted to be satting mid-80s on RA. Slapped on some O2 and sent to the ED. Originally satting mid-90s on 4L NC and admitted to medicine. Progressive deterioration overnight and by the time we see him, he's mid-90s on a non-rebreather with significant inspiratory stridor. Racemic epi hasn't helped and they're giving him a bolus of Solumedrol as we walk in the room.

He's uncooperative with exam, won't/can't open his mouth and his neck is deviated to the left. Unsure if it's muscular resistance or from the mass. He's huffing and puffing in the mid 30s and has significant inspiratory stridor. No ENT in-house. I'm at the bedside, there's an anesthesia attending in-house on OB (plus another anesthesia resident) and a SICU resident in-house. Addendum: Forgot to add in his ABG... 7.30/68/138 on the NRB. May change your management, may not.

What would you guys do? I'll post what I ended up doing later...

I wouldnt touch this dude with a ten-foot-pole.

He's alive now. Youre not gonna make him better by intervening through the mouth. Too many land-mines just waiting to explode.

Yeah, you might get lucky trying to get a tube in, but the risk-benefit ratio is not in your favor, so I wouldnt even attempt it.

Take him to the OR and use the spontaneously-ventilating-anesthetic-of-your-choice...I'd probably start a precedex infusion....or ketamine...

This is trach-country, one way or the other, with the patient breating on his own, boys and girls.

Time to call the ENT-dudes house.

 

[militarymd]

Heliox is a good idea, but with a pO2 of only 168 with a NRB, there probably isn't enough FIO2 in a Heliox.


Sedation.....probably ketamine......make him tolerate the high pCO2.

Maybe attempt FOB intubation while waiting for the ENT to come and do awake trach under local.

 

[Skrubz]

ok, i'm going to preface this by saying that i got really, really lucky with this kid.

now that some of the attendings whom i respect the most have weighed in, this is what happened...

looking at the kid, i definitely felt that he needed to be intubated. given how he looked, i felt that he was getting to ready to go down the tubes but wasn't quite yet circling the drain. i didn't feel that he needed an emergent airway but definitely needed an urgent one.

we moved him up to the ICU and en route i called the OB anesthesia attending (he notified the SICU resident) and the OR anesthesia tech to ask for a fiberoptic/difficult airway cart. my attending agreed that he wasn't emergent yet, so we opted to try an awake nasal fiberoptic. he was either too tired to fight back or just not that strong in general so we didn't need to put him to sleep and we would avoid going through his mouth. no sedation, the ICU fellow and RT held him down and SICU resident stood by, cricothyrotomy kit (from our DA cart) ready to go.

after some nasal phenylephrine, nasal dilation and a little glyco, i went in with the scope through the right nares (mass was in the left neck). he desatted a little to the high-80s/low-90s on RA, so we hooked up some O2 to the fiber. going in from the head of the bed, i could get a decent view of the back of oropharynx but everything else below that was totally distorted (i can't even begin to describe what i was looking at because, honestly, i'm not really what i was looking at). lots of thick creamy secretions didn't help either.

with the O2 through the fiber, he was maintaining sats in the mid-90s so my attending gave me a lot of leeway (and time) just looking around, trying to find something that looked like cords. i saw the epiglottis pretty clearly and thought maybe some cords/tracheal opening a few times, but i had a hard time getting a clear view of anything.

after what seemed like hours (in reality maybe 15-20 minutes?) and literally moments before i was going to give up and hand things over to my attending, i caught a glimpse of tracheal rings. i don't remember passing anything looked like cords. but i dropped the nasal RAE and, thankfully, the stridor stopped, +ETCO2.

the kid got a trach the following day (well, later that afternoon since it was 2 in the morning).

did i do the right thing? well, if i could do it all over again, i'd move him to the OR instead of the ICU. but given how he looked clinically, i'd still have tried an awake nasal fiber before resorting to a trach/cric. UT's trick crossed my mind more than once (thanks for teaching me about it in san diego!). but i still got really, really lucky.

 

[UTSouthwestern]

A.C., the kid's alive. That's all that counts. OR or ICU, he was going to buy a trach, but at least you didn't cause any harm by taking a look with the FOB with a cric kit ready to go. If the kid crashed, the benefits of being in the OR would have been moderate at best (meds depending on your hospital policy, anesthesia machine although vents should be plentiful in the ICU, other surgical equipment and IV equipment should the cric be unsuccessful or you hit a pumper).

The key is that you were calm, patient, and prepared for the worst.

 

[IceDoc]

Aside from doing this in the OR, I'd want a better backup plan. A SICU resident (I presume he was surgical) is usually not ideal for an actual cric. First of all, the res probably hasn't done many of these (if any), and doing it for the first time on someone with a severely distorted airway can quickly lead to badness. To borrow from above, an errant cric would deliver this patient quickly and messily (sic) to the grave. Since you had enough time to FOB, ENT (or someone surgically senior) had enough time to come in while you're working on plan A.

I evaluated a thin, perfect MP I, wide oral excursion 14 year old with a growing anterior mediastinal mass. Where there should have been trachea at the sternal notch, there was something squishy. The trachea was significantly deviated to the right. Despite him being thin and having a long neck, it was incredibly difficult to identify the cricoid cartilage. No way could you have found it while he was losing his airway and desaturating. And remember Jet's trick, if you find it, you can mark the cricoid cartilage with a marker "just in case" before you start your FOB.

Question: What do you do with this 14g angiocath w/ O2 hooked up? Are you actually puncturing the cric membrane and jet ventilating or what?

 

[UTSouthwestern]

Question: What do you do with this 14g angiocath w/ O2 hooked up? Are you actually puncturing the cric membrane and jet ventilating or what?

Correct. Emergency jet ventilation. Having had to use it emergently, I can tell you that it works and when I used to take overnight call, I carried a prepacked kit in my carry pack as a safety measure.

Just be sure to use a syringe on the 14 ga angiocath to aspirate while advancing the needle and cath. Ventilating an artery or vein would be considered extremely poor form.

 

[TheSandMan]

Correct. Emergency jet ventilation. Having had to use it emergently, I can tell you that it works and when I used to take overnight call, I carried a prepacked kit in my carry pack as a safety measure.

Just be sure to use a syringe on the 14 ga angiocath to aspirate while advancing the needle and cath. Ventilating an artery or vein would be considered extremely poor form.

Damn y'all are pimps! 👍 Start my CA1 this July and reading this thread has definitely got me fired up. Hopefully will have something positive to contribute in the future, but till then will keep reading and learning.

ps. by "carry pack" r u talking about one of those fanny packs. Don't know if I can pull off one to those. Anyway to be good and get away with not wearing one 🙄

 

[UTSouthwestern]

ps. by "carry pack" r u talking about one of those fanny packs.

HELL no. Never carried those fanny packs at any time in my life. Carry pack = satchel, not butt pack.

 

[Skrubz]

Aside from doing this in the OR, I'd want a better backup plan. A SICU resident (I presume he was surgical) is usually not ideal for an actual cric. First of all, the res probably hasn't done many of these (if any), and doing it for the first time on someone with a severely distorted airway can quickly lead to badness. To borrow from above, an errant cric would deliver this patient quickly and messily (sic) to the grave. Since you had enough time to FOB, ENT (or someone surgically senior) had enough time to come in while you're working on plan A.

Good point, IceDoc. If I had to do this all over again, I would definitely call ENT as we're rolling up to the OR/ICU.

And I'd like to say for the record that I too do not wear a fanny pack. I thought about it (the program actually gives us one, stamped with "Zemuron"). Instead, I have a "man-bag" by Manhattan Portage. It carries my PDA, a couple small handbooks, my nerve stimulator and some emergency drugs. I'm considering buying a slightly larger bag though, so I can start lugging around a small text for downtime reading.

 

[zippy2u]

Wow Dude, that "man-bag" looks ta Zip like somethin' one of those new age metrosexuals ya see in the big cities runnin' around with. They put all their goodies in those bags like facial "pretty-boy" creams and gels, KY jelly, condoms, assortment of "flavored" thongs and jizz "hankies". Trust me dude, leave all clown bags at home... Regards, ----Zip

 

[jetproppilot]

Correct. Emergency jet ventilation. Having had to use it emergently, I can tell you that it works and when I used to take overnight call, I carried a prepacked kit in my carry pack as a safety measure.

Just be sure to use a syringe on the 14 ga angiocath to aspirate while advancing the needle and cath. Ventilating an artery or vein would be considered extremely poor form.

Uhhh, UT,

PLEASE, PLEASE tell me you don't wear a fanny pack.

 

[jetproppilot]

HELL no. Never carried those fanny packs at any time in my life. Carry pack = satchel, not butt pack.

(WHEW ).

Just read this.

 

[zippy2u]

Sorry about gettin' side tracked with that "man-bag" situation... Go assess pt. Yeah he needs an awake trach. Stat consult ENT resident and tell him your concerns. Hopefully, he's one of those I-like-to-do-trachs-at-2AM kind o' residents. Call the anesthesia resident and tell him to bring the pt. back to the MICU paralyzed with a long acting agent and gorked on versed and fentanyl. Next,call respiratory person with initial vent settings when the guy gets back to the unit. Since you're probably in a teaching hospital and it's 1AM, this is a 3 hour nightmare ordeal by the time everybody gets their shiit together. Don't do anything in the MICU, the pt. needs to go straight to the OR. Blow off heliox, jet ventilation, CPAP, awake FOB, cricothyrotomy yada yada yada. Go back to sleep until AM rounds. Regards, ---Zippy

 

[cloud9]

Good point, IceDoc. If I had to do this all over again, I would definitely call ENT as we're rolling up to the OR/ICU.

And I'd like to say for the record that I too do not wear a fanny pack. I thought about it (the program actually gives us one, stamped with "Zemuron"). Instead, I have a "man-bag" by Manhattan Portage. It carries my PDA, a couple small handbooks, my nerve stimulator and some emergency drugs. I'm considering buying a slightly larger bag though, so I can start lugging around a small text for downtime reading.

Dude, I'd wear the fanny before I'd wear that. It looks like those cute little useless backpack-type-thingys the ladies have been wearing the past couple of years. But hey, maybe I'm just not masculine enough to carry one of those off.

 

[SouthSideSteve]

Dude, I'd wear the fanny before I'd wear that.

So are tackle boxes out? And what all do people carry in their tackle boxes/man bags/fanny packs? Drugs and supplies for procedures and emergency stuff like the 14ga jet ventilation?

 

[militarymd]

Carries everything you will need....Never leave home without it.

 

[Sugar72]

Carries everything you will need....Never leave home without it.

but does it come in pink like the man bag does?