Oral board case in real life

[cchoukal]

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This JUST happened to me.

In the ED seeing another patient. ED resident hurriedly whisks you off to the resuscitation room and tells you there's a fat black lady with anaphylaxis to a peanut allergy who need to be intubated. At the bedside, you see she is middle-aged, obese (+/- 300lbs), no IV, in respiratory distress, writhing around and gasping for air. There's no BP, SpO2, or EKG (this IS the ED after all, although she's flailing around so much, nothing's working). She has received bronchodilators, epi nebs, and IM epi.

Your move!

 

[SleepIsGood]

This JUST happened to me.

In the ED seeing another patient. ED resident hurriedly whisks you off to the resuscitation room and tells you there's a fat black lady with anaphylaxis to a peanut allergy who need to be intubated. At the bedside, you see she is middle-aged, obese (+/- 300lbs), no IV, in respiratory distress, writhing around and gasping for air. There's no BP, SpO2, or EKG (this IS the ED after all, although she's flailing around so much, nothing's working). She has received bronchodilators, epi nebs, and IM epi.

Your move!

Call for help...IE have ENT notified.

Have Glidescope, FO Bronchoscope by bedside, intubating LMA

Have someone look for an IV

optimize pt's position (put ramp of life). Since you have an albuterol neb going, once that's done, try to get some lido nebulized and going. If you can get a transtrach lido try it. Hurrican spray lips/oropharnyx and as low as you can get. Do awake fiberoptic/glidescope. Put tube in. Check CO2 by capnometry (hopefully by respiratory guys). B/L BS. Give ketamine. Push roc/etc. Ventilator

 

[BLADEMDA]

GEt Glidescope, Fiberoptic scope, etc. as your back up. Get a second set of hands (yes, even a CRNA here).

Also, I hope your E.R. has INTRAOSSEOUS INFUSION EQUIP like mine. You may need it here (still may need I.M. Ketamine even to get that intraosseous line). Consider central line but intraosseous is faster.

http://www.fast1sternal.com/

http://www.vitaid.com/usa/ez-io/index.htm

By the way we intubate 300 pounders every day with no problems. In fact, most have Class 1 airways.

 

[cchoukal]

Excellent. Glidescope, airway cart, intraosseus prepped and ready, Surgery at the bedside w/ crich kit open. 22g IV established in the foot. Patient thrashing wildly. Three different ER physicians are holding up syringes, offering to push propofol, etomidate, and ketamine. Jackson-Rees to face, patient moving decent volumes, but flailing and unable to sit still for anything (i.e., difficult to topicalize, anticipating difficult awake intubation).

In the end, my goal was to maintain spontaneous ventilation. IV ketamine, DL, unable to pass ETT before patient woke up and started biting (ER only had 200mg of ketamine in whole department, somehow). Ultimately did an awake glidescope.

I wanted to post this case because, in the moment, there was a lot of chaos and a lot of people offering different suggestions, and it felt very much like the mock oral exams I did in residency (e.g., "the janitor suggests you give propofol, would you do it?"). Lots of people were shouting lots of different things and really pressuring me to put her to sleep. In the end, I'm glad I didn't.

Blade, I agree with you about the obese airway and I don't always get a lot of buy-in on that point. We did a lot of bariatric surgery in residency, and although often a difficult mask, they're frequently easy to intubate. She, it turned out was not, although conditions were less than optimal.

 

[fastosprintini]

excellent post cchoukal!
i do think that the take home message is not to get flustered because people try to make you do something they have no understanding of.
if somebody calls me to bail them out they need to understand that it gets done on my terms...
calling for skilled help (as in no obsterician, janitor , hospital ceo etc.) is crucial, have no pride and call early , this is a sign of strength, not weakness .
the choice of airway devices is more or less semantic, what ever YOU are comfortable and skilled with is fine.
fasto

 

[SleepIsGood]

Excellent. Glidescope, airway cart, intraosseus prepped and ready, Surgery at the bedside w/ crich kit open. 22g IV established in the foot. Patient thrashing wildly. Three different ER physicians are holding up syringes, offering to push propofol, etomidate, and ketamine. Jackson-Rees to face, patient moving decent volumes, but flailing and unable to sit still for anything (i.e., difficult to topicalize, anticipating difficult awake intubation).

In the end, my goal was to maintain spontaneous ventilation. IV ketamine, DL, unable to pass ETT before patient woke up and started biting (ER only had 200mg of ketamine in whole department, somehow). Ultimately did an awake glidescope.

I wanted to post this case because, in the moment, there was a lot of chaos and a lot of people offering different suggestions, and it felt very much like the mock oral exams I did in residency (e.g., "the janitor suggests you give propofol, would you do it?"). Lots of people were shouting lots of different things and really pressuring me to put her to sleep. In the end, I'm glad I didn't.

Blade, I agree with you about the obese airway and I don't always get a lot of buy-in on that point. We did a lot of bariatric surgery in residency, and although often a difficult mask, they're frequently easy to intubate. She, it turned out was not, although conditions were less than optimal.

nice job👍

Let me tell you, I think if done right, awake glidescope is a very well tolerated and safe procedure. My n=2 on this. For the anesthesiologist, I think it's better than a FOBronchoscope because you can look up and see the patient and the vocal cords etc. with a FOI (unless you blow it up on a screen) your eye are in the scope and nowhere else.

 

[cchoukal]

nice job👍

Let me tell you, I think if done right, awake glidescope is a very well tolerated and safe procedure. My n=2 on this. For the anesthesiologist, I think it's better than a FOBronchoscope because you can look up and see the patient and the vocal cords etc. with a FOI (unless you blow it up on a screen) your eye are in the scope and nowhere else.

Big fan of the awake Glide (but then, I'm a big fan of the awake DL also).

And I had a lot of help. Out of nowhere appeared 2 anesthesiologists (they were new graduates bored in the OR prepping for their oral boards!) and a fantastic anesthesia tech.

 

[Noyac]

By the way we intubate 300 pounders every day with no problems. In fact, most have Class 1 airways.

I agree totally. The obese are "usually" very easy to intubate.

 

[Planktonmd]

Once you had that 22 Gauge in the foot the next step should have been Propofol, Sux, Tube.

 

[SleepIsGood]

Once you had that 22 Gauge in the foot the next step should have been Propofol, Sux, Tube.

except on the oral boards