Overhead paged to er for airway

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True case... Give me your take and I'll tell you later how it worked out.

Overhead paged "anesthesia stat to er." upon arrival I find er doc and rt holding mask in front of patients face. He looks large, maybe 6'2" 110 kg. Story is he had metal device dropped on his neck, anteriorly while supine working in a machine shop. Metal equipment was about 250 lbs.

Pt is coughing up blood, sats 90%, awake/alert, in lots of pain. Neck is visibly swollen anteriorly. Mild crepitus in anterior chest. Pulmonary doc is getting fiberoptic out and now he's taking a look but really just keeps suctioning blood.

What do you do??
 
Call ghostbusters, because this guy is gonna be a ghost soon.

Maybe ENT, that way you don't need the ghostbusters.

If the ENT fails, CPB?

I'd probably avoid the pavulon on this one.
 
Sounds a lot like this- http://sports.espn.go.com/ncf/news/story?id=4512778

Plan A- The ENT appeals to a divine power (hopefully choosing the correct one!), applies cold steel, successfully does the trach, then Tebows.

Plan B- Since you're in a fancypants academic center with perfusionists and cardiac surgeons sitting around playing Sudoku, you snap your fingers and- voila!- you've instituted V-V ECMO.

Plan C- Ketamine, try to intubate from above, don't force anything. He's still alive so there's some conduit of air from his glottis to his bronchi. Try to put your tube there. Once through the cords you could try putting the FO through the tube to see what was ahead, but all you'll see will probably be blood. Alternatively, once through the cords you could try a tube exchanger or bougie or something to get past the injury if tube passage is difficult, knowing that you could well dissect into soft tissue. Good luck!
 
My initial thought was page ENT/Sg for awake Trach.

He's moving air, be ready to go to plan B at any moment.
 
For all you awake trach votes- sats are not holding up and his neck looks like a sausage.
 
Surfer said:
For all you awake trach votes- sats are not holding up and his neck looks like a sausage.
Click to expand...

I vote not so awake trach...

Trach is plan A, if the guy is going to die on you before ENT can get there you can go for the Hail Mary and intubate; he might not be that difficult...
Does he look like you can mask him?
 
Two things:

1. If you have no surgeon coming or not immediately available, open up his neck! If his neck is a sausage and he's bleeding into his neck, open it and relieve the pressure. Open up the IVF's. A small incision along the SCM should give you access to the hematoma. If you can't or don't want to do that, keep his postural angle high because he is about to be strangulated subcutaneously.

2. Cric him or Q&D trach him. You can go for the Hail Mary DL but remember this guy suffered a severe trauma with 250 pound object landing on his head. The degree of retrolisthesis is probably severe with developing cord injury and swelling, and not only does he have vascular injuries to the neck, he likely has a tracheal injury as well as indicated by the crepitus. Aside from the risks of manipulating his head with an unstable/post trauma neck, the crepitus in his chest indicates a tracheal injury likely near the carina. If you intubate from up high and lodge above the tear, you may blow the majority of the oxygen out of the tracheal injury, especially if you haven't opened his neck to alleviate the increasing pressure of his hematoma which could act as a collar at any point along the trachea, preventing you from getting deep enough to ventilate effectively.

Slap a suction tube with a bite guard or a Yankhauer into the side of his mouth to continuously suction out the blood. You don't need him thrashing about because he is drowning on his own fluids. Tape either one into a reasonable position that allows for maximum clearance with minimal effort.

If it sounds like I've done this before, it's because I have. Don't mess around on patient like this. My patient was a mover that had a refrigerator land on his head.
 
Good to hear from you UTSW!!! Still in my thoughts and prayers...

as for the case... I did nothing. I watched them try to maintain his sats awake which they couldn't do. Then they tried sedating him and bagging him, which was unsuccessful. Finally they asked ENT to do an emergent bed-side cric, which they did with some difficulty. Remember, his neck was swollen, so landmarks were difficult. they eventually got it but noticed significant tracheal compromise, so they took him to the OR for emergent tracheal reanastomosis.

In retrospect, I'm glad i did nothing. I'm 100% sure I could have put a tube between his cords, but then what? The trachea was all torn up! I would have inflated his chest. Now getting some o2 down a torn trachea is certainly better than not getting O2 into a torn trachea, but you get the drift.

I present this case because sometimes its best to step aside and let somebody else fumble their way into the endzone. Patient lived, walked out of the hospital a few days later. Had i stuck a tube in there or attempted a surgical airway i would have probably killed him. but of course, if ENT wasn't around it would have been worth a shot because he was going to die anyways...
 
Surfer said:
Good to hear from you UTSW!!! Still in my thoughts and prayers...

as for the case... I did nothing. I watched them try to maintain his sats awake which they couldn't do. Then they tried sedating him and bagging him, which was unsuccessful. Finally they asked ENT to do an emergent bed-side cric, which they did with some difficulty. Remember, his neck was swollen, so landmarks were difficult. they eventually got it but noticed significant tracheal compromise, so they took him to the OR for emergent tracheal reanastomosis.

In retrospect, I'm glad i did nothing. I'm 100% sure I could have put a tube between his cords, but then what? The trachea was all torn up! I would have inflated his chest. Now getting some o2 down a torn trachea is certainly better than not getting O2 into a torn trachea, but you get the drift.

I present this case because sometimes its best to step aside and let somebody else fumble their way into the endzone. Patient lived, walked out of the hospital a few days later. Had i stuck a tube in there or attempted a surgical airway i would have probably killed him. but of course, if ENT wasn't around it would have been worth a shot because he was going to die anyways...
Click to expand...

Wish I had that option. No ENT available within 20 minutes drive time (late night), no general surgeon available, CT case I was called in for cancelled for low platelets, likely HIT, and no donor platelets available. Just about to step out of the OR when the call came through.

Your patient is lucky to walk out. Mine eventually did but suffered a C4-C6 anterior ischemic injury and lost use of both arms, although I followed up with him and six months later, he could lift both and do basic activities of daily living. The refrigerator was being lowered by another guy from the second level of a two level truck and the guy lowering it inexplicably let go and it crashed directly onto my patient's forehead with about 5 feet of acceleration distance.

When I popped past the SCM, a flood of fresh blood and clots came pouring out. At least a liter (guy is 6'3, 280 African American former college lineman) came out. I did see an artery pumping and did clamp it, but I knew the contralateral side was likely full of bleeders too. All throughout this part, he toughed it out with local and 2 cc's fentanyl. His breathing improved but he kept coughing up blood in heavy quantities and each time he did, we saw bubbles coming out of the incision and his head and neck would move significantly even with in line stabilization. Sats dropped into the 70's on nasal cannula with NRB over the top and his lungs sounded very crappy. He also was just starting to wear out. I explained quickly what I was going to do. I asked him to take as many big deep breaths as possible, numbed his neck thoroughly, gave him another cc of fentanyl and took the plunge with the Melker cric kit. The wire went in and he coughed appropriately. I decided to cut down along the wire to the trachea and was greatful I did because the trach tear was below wire entry point and large enough that the crich tube was not large enough to tamponade the damage point.

I had already asked the nurses and RT's to get every size Shiley trach tube available as I didn't know what size was what so we opened the second largest and it fit through incision I made above the wire and extended far enough to tamponade the injury and allow him to ventilate effectively. We actually didn't have to put him on mechanical ventilation, but because of his neck stability issues and the fact we were not sure when a neurosurgeon would be available, we did eventually and suctioned out a ton of blood.

More to come later.
 
Good case discussion.
I wouldn't cowboy an ETT from above in a suspected cervical injury patient unless he looked like the easiest airway on earth, and I certainly wouldn't in a suspected or known tracheal injury. Once you're past the cords you're in unknown territory and you could make things much worse and assassinate him. If you're going from above use a fiber and put the tube in deep. I've done a couple dog bites to the neck on kids with a fiber from above. Cric kit or surgical cricothyroidotomy is probably how I would have proceeded in this case. Likely the latter as I would want to drain the hematoma.
I like the idea of opening the neck to drain the expanding hematoma. I've done it once with a neck exploration kid who bled overnight. Pretty impressive. Relieved the tracheal deviation and compression. Easy DL, spont vent etc. etc.
For the guys who are hoping ENT will take it for you, most hospitals you're going to work in are not going to have in house ENT 24/7, and if they're there, they're probably in the OR working. So have a few plans ready yourself. Know your kits, etc. I probably would have put in a 5 cuffed tube through the surgical cric. It's immediately available, long enough to place right above the carina, and you can fiber though it and suction the lungs out with a good sized bronchoscope.
Sometimes nothing is the best course though. Optimize the ventillation and wait for the cavalry. Good job.
Retrograde wire is good for a lot of pathology above the trachea, but you wouldn't know if you were in the trachea or a subcutaneous air pocket when you tried to pass the wire. You also wouldn't know if the tube went past the tracheal injury or through it, making it worse. I've had the jet vent (a horrible choice for this case BTW) and the retrograde wire kit ready for known difficult fiber intubations in the past. Never had to use it.
 
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I think we all should know the anatomy of the neck and be prepared to open a neck and to perform a cric/trach if needed. I know that sounds crazy to some but its your @ss on the line someday and having that knowledge could be very valuable. We recently had a youngish healthy guy come in for a routine thyroid, developed a hematoma 6 hours post-op, died en route from the floor to the OR because no one wanted to open the neck (intern mistake) and by the time he got to the OR it was over. So stupid. I performed a formal trach my intern year with the attending just sitting there talking me through it, it isn't friggin rocket science, know the steps to a cric and trach and have it as a last resort.

PS- In an ideal world I would have asked that a CT surgeon be available, instead of ENT, in the event that you needed a trach, the likelihood of low tracheal injury/tear and the possibility of chest-wall damage.
 
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Good points to follow up on.

To continue with the story, a vascular surgeon called by the ER guy was the first guy to show up and he was upset that I opened the neck. Started to give me an earful which earned him a "would you prefer a dead patient or live one?" response from me. I stand my ground. Ironically, the ENT arrives immediately after him and asks who did the cric? The vascular surgeon couldn't hold back his glee pointing at me and booming out "him". ENT comes up to me and says, "pretty damn good job, did you do a surgery internship?"

Told him we know what had to be done, just had to do it. We get the patient to CT/MRI and scan him. We can't wait for the neurosurgeon so we head to the OR and I ask both surgeons to leave the right side of the neck as clear as possible as the neurosurgeon coming in always operates through the right side. Upon dissecting the neck, the ENT counts 6 vascular tears, including two small arterial branches off the L carotid, plus my larger one on the right. Repairs were done and everything closed and the ENT left the Shiley in the same spot I placed it, which irked the vascular surgeon, who wanted the ENT to criticize my trach placement.

Unfortunately, despite starting the patient on steroid protocol and cooling him prior to the arrival of the neurosurgeon, the patient still had a cord ishemic event. Took 8 more hours to stabilize his neck anteriorly and posteriorly.

Of course to top off everything off, case is a freebie, no insurance of any kind.

As posted, know when to defer to ENT, but know what to do regardless and don't hesitate to do it. A life is in your hands and you trained to save lives, not avoid responsibility when you are the one to act.
 
UTSouthwestern said:
Good points to follow up on.

To continue with the story, a vascular surgeon called by the ER guy was the first guy to show up and he was upset that I opened the neck. Started to give me an earful which earned him a "would you prefer a dead patient or live one?" response from me. I stand my ground. Ironically, the ENT arrives immediately after him and asks who did the cric? The vascular surgeon couldn't hold back his glee pointing at me and booming out "him". ENT comes up to me and says, "pretty damn good job, did you do a surgery internship?"

Told him we know what had to be done, just had to do it. We get the patient to CT/MRI and scan him. We can't wait for the neurosurgeon so we head to the OR and I ask both surgeons to leave the right side of the neck as clear as possible as the neurosurgeon coming in always operates through the right side. Upon dissecting the neck, the ENT counts 6 vascular tears, including two small arterial branches off the L carotid, plus my larger one on the right. Repairs were done and everything closed and the ENT left the Shiley in the same spot I placed it, which irked the vascular surgeon, who wanted the ENT to criticize my trach placement.

Unfortunately, despite starting the patient on steroid protocol and cooling him prior to the arrival of the neurosurgeon, the patient still had a cord ishemic event. Took 8 more hours to stabilize his neck anteriorly and posteriorly.

Of course to top off everything off, case is a freebie, no insurance of any kind.

As posted, know when to defer to ENT, but know what to do regardless and don't hesitate to do it. A life is in your hands and you trained to save lives, not avoid responsibility when you are the one to act.
Click to expand...

Love, love, love it. 😍

Well done UT. It takes guts to open up a real neck hematoma and clamp a vascular structure, followed by a cric. Especially with no ENT or vascular surgeon around. Can't say I've opened a neck hematoma or performed a cric... but I can tell you I'll be making diamonds if I ever get in that position. 😀 Well done.👍

Big congrats on the 6 mo. mark....:woot: Bravo!
 
ENT? Hell no. Page Oral Surgery, DDS - hand skills baby!
 
SitraAchra said:
Shhh, the grown ups are talking. Just listen and learn - like me. Don't embarrass yourself.
Click to expand...

Lol.👍:laugh: Maybe his wisdom teeth got physically moved to the trachea?
 
First off, I apologize for my divine power remark in a previous post, it was callous. Sorry if anyone was offended.

Second, in the right place and time, the V-V ECMO thing really might work. It'd be a hail mary, sure, but lifesaving if the right people were around to make it happen.

UT- you're a badass, sir. What you did was amazing. I'd like to think that, confronted with the same situation, I would/could have done the same thing. I've done formal trachs in the ICU, I've done crics on mennequins, and done emergency trachs on cadavers. So as long as the anatomy is the way it should be, and blood isn't spurting anywhere, sure, I'd be cool.

But in the presence of grossly distorted anatomy, vascular injuries, and poor visualization, I dunno. Especially since my malpractice climate is markedly different from yours, I'd be pretty hesitant to pull that trigger and dive in. If the patient was actively dying, though, I guess I'd take a deep breath and give it a shot. Maybe.
 
Good discussion to have the presence of mind to cut the neck to evacuate a hematoma when necessary.

Just to throw some other thoughts in. Praying for guidance I might have considered the following possibly lethal approach:

Patient sitting up, ketamine, droperidol, scopolamine (have mercy on awareness).
Have a BFI with O-blood on the way and start giving it kind nurse.

I might take an awake look with the Glidescope while the patient is sitting upright frozen on droperidol. Ideally I'd have a pediatric FOB railroaded by a Cook Airway catheter--something through which you can insufflate/apneic oxygenate. Looking for the bubbles under direct Glidescope/FOB vision I'd implore the Lord and make haste for the carina (or further) leaving the Cook Airway in deep. Maybe put a tube over the Cook afterward, maybe start work on the cric/trach instead.

Another thought, I might have the guy swallow an LMA awake that could then be used as a conduit for the FOB/Cook.

I carry a cricothyrotomy kit (we received as graduating resident presents), so would probably go midline as low as possible with the BF hollow needle then Seldinger wire and advance a tube changer or some small Frenchl oxygen conduit over it. I'm probably more lethal with a scalpel, but hope I'd go to it if necessary.

After all that I'd call home for a change of underwear, and start looking for pneumo
 
Hawaiian Bruin said:
But in the presence of grossly distorted anatomy, vascular injuries, and poor visualization, I dunno. Especially since my malpractice climate is markedly different from yours, I'd be pretty hesitant to pull that trigger and dive in. If the patient was actively dying, though, I guess I'd take a deep breath and give it a shot. Maybe.
Click to expand...

Pretty much how I feel about it as well. Tough call.
 
pgg said:
UTSW, I think that story just embodies the kind of knowledge, talent, ability, and intangible heroic calm we all aspire to have. Great case, thanks for sharing it.
Click to expand...

Calm is the key. You should never get nervous because you have the knowledge and skills, you just need to trust yourself to do it.

Regarding the malpractice situation, it is a tough call, but it can swing both ways: You might get sued for not diving in and doing something.
 
I agree with this. I would basically go with the RSI protocol + ETI + suction and drop a tube. This is of course - assuming you have the hand skills 👍

UTSouthwestern said:
Calm is the key. You should never get nervous because you have the knowledge and skills, you just need to trust yourself to do it.

Regarding the malpractice situation, it is a tough call, but it can swing both ways: You might get sued for not diving in and doing something.
Click to expand...
 
yappy said:
I agree with this. I would basically go with the RSI protocol + ETI + suction and drop a tube. This is of course - assuming you have the hand skills 👍
Click to expand...

And you run the risk of driving the tube into the known tracheal injury and assassinating the patient. In my opinion tracheal injuries require a fiber, and this was an obvious tracheal injury. UT's case needed the neck cut, fiber isn't an option for aggressive bleeding, and cowboying a tube in an unstable neck is a bad idea for multiple reasons. Of course you've got mad hand skills, so I'm sure you'll devine the correct path blindly from above through the disrupted trachea, all the while keeping proper inline stabilization in your patient with grossly distorted neck anatomy.
I think you should rethink your plan.
 
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yappy said:
I agree with this. I would basically go with the RSI protocol + ETI + suction and drop a tube. This is of course - assuming you have the hand skills 👍
Click to expand...

Your status is listed as "pre-health" ... is that accurate? Just curious where you're coming from with this plan and "hand skills" talk.
 
pgg said:
Your status is listed as "pre-health" ... is that accurate? Just curious where you're coming from with this plan and "hand skills" talk.
Click to expand...

Considering his response to an incredibly nuanced and difficult airway disaster is "a basic RSI and drop a tube," just another pretender who's had at most a few months of anesthesia training so he can do his own procedures in the dentist office.

Zero respect for a critical airway which he'll never come across as evidenced by perseveration on "hand skills" and an absurd belief that a dentist would be more valuable than an ENT if you need access to a trachea quickly.

You hear me Yappy? This isn't a "I chipped my front teeth and prom is tomorrow" emergency. This is "in 5-10 minutes the patient is dead unless UTSW/similarly trained Sully kinda mofo" is on staff.
 
I'm sorry for intruding on your boards guys. In full disclosure I'm not a medical doctor. I was just kidding around.

I was trained to the level of a paramedic in the airforce in my PJ technical school. Since I've been out I've been cashing the educational money and am going for dentistry. Yes, I am a predent.

I respect what you guys do! You're the king of airway.

Sorry to detract from your discussion. I found this thread interesting and thought I would make a joke about OMS vs ENT.

SitraAchra said:
Considering his response to an incredibly nuanced and difficult airway disaster is "a basic RSI and drop a tube," just another pretender who's had at most a few months of anesthesia training so he can do his own procedures in the dentist office.

Zero respect for a critical airway which he'll never come across as evidenced by perseveration on "hand skills" and an absurd belief that a dentist would be more valuable than an ENT if you need access to a trachea quickly.

You hear me Yappy? This isn't a "I chipped my front teeth and prom is tomorrow" emergency. This is "in 5-10 minutes the patient is dead unless UTSW/similarly trained Sully kinda mofo" is on staff.
Click to expand...
 
UTSouthwestern said:
Wish I had that option. No ENT available within 20 minutes drive time (late night), no general surgeon available, CT case I was called in for cancelled for low platelets, likely HIT, and no donor platelets available. Just about to step out of the OR when the call came through.

Your patient is lucky to walk out. Mine eventually did but suffered a C4-C6 anterior ischemic injury and lost use of both arms, although I followed up with him and six months later, he could lift both and do basic activities of daily living. The refrigerator was being lowered by another guy from the second level of a two level truck and the guy lowering it inexplicably let go and it crashed directly onto my patient's forehead with about 5 feet of acceleration distance.

When I popped past the SCM, a flood of fresh blood and clots came pouring out. At least a liter (guy is 6'3, 280 African American former college lineman) came out. I did see an artery pumping and did clamp it, but I knew the contralateral side was likely full of bleeders too. All throughout this part, he toughed it out with local and 2 cc's fentanyl. His breathing improved but he kept coughing up blood in heavy quantities and each time he did, we saw bubbles coming out of the incision and his head and neck would move significantly even with in line stabilization. Sats dropped into the 70's on nasal cannula with NRB over the top and his lungs sounded very crappy. He also was just starting to wear out. I explained quickly what I was going to do. I asked him to take as many big deep breaths as possible, numbed his neck thoroughly, gave him another cc of fentanyl and took the plunge with the Melker cric kit. The wire went in and he coughed appropriately. I decided to cut down along the wire to the trachea and was greatful I did because the trach tear was below wire entry point and large enough that the crich tube was not large enough to tamponade the damage point.

I had already asked the nurses and RT's to get every size Shiley trach tube available as I didn't know what size was what so we opened the second largest and it fit through incision I made above the wire and extended far enough to tamponade the injury and allow him to ventilate effectively. We actually didn't have to put him on mechanical ventilation, but because of his neck stability issues and the fact we were not sure when a neurosurgeon would be available, we did eventually and suctioned out a ton of blood.

More to come later.
Click to expand...

From a technical standpoint, why did you decide to cut "along the SCM"?

Where excactly (I know it will be difficult to describe with images) did you cut?

Thanks for the education, HH

And why did you choose to put in a Shiley instead of getting extra "distance" with an ETT past potential tracheal tears?

Curious, HH
 
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Hamhock said:
From a technical standpoint, why did you decide to cut "along the SCM"?

Where excactly (I know it will be difficult to describe with images) did you cut?

Thanks for the education, HH

And why did you choose to put in a Shiley instead of getting extra "distance" with an ETT past potential tracheal tears?

Curious, HH
Click to expand...

Closest I could get to the carotid and IJ. I didn't want to cut so far laterally that I might miss the pocket of hematoma and not have any decompressive effect whatsoever. Was I risking hitting the carotid and IJ? Yes, but I made sure to bluntly dissect most of the last 1/3 of the penetration depth with the small clamps we had available.

Medial border of the SCM directed posteriorly and medially. Was really the only muscle palpable at this point and partly guesswork.

I already planned to cut down along the wire to try to get at least a partial visual of the tracheal injury. It was very bloody but we had good suction and lots of sterile 4X4's. I could have used the ETT's but we had the Shiley's available, hoping ENT or any surgeon would stroll in in the middle of the procedure.
 
UTSouthwestern said:
Closest I could get to the carotid and IJ. I didn't want to cut so far laterally that I might miss the pocket of hematoma and not have any decompressive effect whatsoever. Was I risking hitting the carotid and IJ? Yes, but I made sure to bluntly dissect most of the last 1/3 of the penetration depth with the small clamps we had available.

Medial border of the SCM directed posteriorly and medially. Was really the only muscle palpable at this point and partly guesswork.

I already planned to cut down along the wire to try to get at least a partial visual of the tracheal injury. It was very bloody but we had good suction and lots of sterile 4X4's. I could have used the ETT's but we had the Shiley's available, hoping ENT or any surgeon would stroll in in the middle of the procedure.
Click to expand...
Why not a midline vertical incision?
 
nitroglycerine said:
Why not a midline vertical incision?
Click to expand...

I wanted to to be sure I got into the hematoma. On both sides, the patient's neck was bulging significantly, but midline, I wasn't sure I could or wanted to try to dissect from midline to a lateral compartment to hunt for the hematoma. I just wanted to hit it fast and decompress it.
 
When I was rotating on general surgery and doing a thyroid case the attending pimped me on what to do for acutely dyspneic patient s/p thyroidectomy. I had no idea 'reopen the neck' was the right answer (under the right circumstances with other signs that you've got a hematoma), but I'll never forget now.
 
UTSouthwestern said:
Closest I could get to the carotid and IJ. I didn't want to cut so far laterally that I might miss the pocket of hematoma and not have any decompressive effect whatsoever. Was I risking hitting the carotid and IJ? Yes, but I made sure to bluntly dissect most of the last 1/3 of the penetration depth with the small clamps we had available.

Medial border of the SCM directed posteriorly and medially. Was really the only muscle palpable at this point and partly guesswork.

I already planned to cut down along the wire to try to get at least a partial visual of the tracheal injury. It was very bloody but we had good suction and lots of sterile 4X4's. I could have used the ETT's but we had the Shiley's available, hoping ENT or any surgeon would stroll in in the middle of the procedure.
Click to expand...

Amazing case, thanks for sharing, UT.
 
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