Parkinson's Disease & Intubation

[signomi]

I have a question I need help with. I am an internist that runs the code team at night when I work. The other night I was called to a code. The patient was 87 and had Parkinson's disease and dementia. She had a PEG and hadn't eaten in years, also she was non-verbal. Let's say her jaw didn't see any use. I never got a straight answer as to why her jaw was frozen one inch open.
I could get the scope in, but her head was stuck in flexion, so there was no chance of extending her neck. Her teeth were all broken and sharp so I was ripping open my fingers trying to force her jaw open. Several people tried, but this was apparently a problem before the code. I even hit her with pancuronium to see if we could loosen it up. Nope. There was zero chance of seeing the cords. I tried blind insertion and probably because of her permanent shoulder and neck flexion, it went nowhere (it was 7.0). I tried the 4.0 LMA...and it didn't even fit between her teeth. We had to bag her during the code. She stayed in asystole for 35 minutes, so we called it.

So, my question, short of cricothyroidotomy, what were my options? Those are the only two pieces of equipment this small hospital carries. Are there any nasal tubes you have had success with? The hospital might be persuaded to purchase a third line option for these kind of cases.

And before someone asks, no it wasn't rigor mortis, it was a witnessed arrest.

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[jetproppilot]

I have a question I need help with. I am an internist that runs the code team at night when I work. The other night I was called to a code. The patient was 87 and had Parkinson's disease and dementia. She had a PEG and hadn't eaten in years, also she was non-verbal. Let's say her jaw didn't see any use. I never got a straight answer as to why her jaw was frozen one inch open.
I could get the scope in, but her head was stuck in flexion, so there was no chance of extending her neck. Her teeth were all broken and sharp so I was ripping open my fingers trying to force her jaw open. Several people tried, but this was apparently a problem before the code. I even hit her with pancuronium to see if we could loosen it up. Nope. There was zero chance of seeing the cords. I tried blind insertion and probably because of her permanent shoulder and neck flexion, it went nowhere (it was 7.0). I tried the 4.0 LMA...and it didn't even fit between her teeth. We had to bag her during the code. She stayed in asystole for 35 minutes, so we called it.

So, my question, short of cricothyroidotomy, what were my options? Those are the only two pieces of equipment this small hospital carries. Are there any nasal tubes you have had success with? The hospital might be persuaded to purchase a third line option for these kind of cases.

And before someone asks, no it wasn't rigor mortis, it was a witnessed arrest.

Not monday-night-quarterbacking. You were there, I wasnt.

But heres some thoughts.

Someone stuck in cervical flexion is calling for intubation by a Mac blade.

So even though I always use a Miller 2, I wouldda looked with a Mac 3. Sounds like optimum conditions for that blade.

And even if your view is sub-optimal, a bougie may have been able to pass, with a tube-over-the-bougie to folllow.

But then again maybe not.

Bottom line, if you've got a difficult airway, you've taken a cuppla looks with no luck, time to call the anesthesiologist.

We do this every day. All day.

And we're here to help you in these difficult situations.

 

[signomi]

There is no in-house night time anesthesiologist. Question: how do you verify bougie placement?
Oh and I was using a mac blade.

 

[jetproppilot]

There is no in-house night time anesthesiologist. Question: how do you verify bougie placement?
Oh and I was using a mac blade.

Good question, Sig.

From an anesthesiologist point of view, most of the time, you know whether you're there or not. Maybe you see the bottom of the aretynoids, cant quite drive the tube in, so you elect to guide in a bougie.

I can't emphasize enough the great utility of the bougie. Has saved me countless time......don't have to pull out the fiberoptic stuff....

answer to your question is that you verify placement by guiding the tube over the bougie, removing the bougie, inflating the ETT balloon, and seeing if you have breath sounds/chest going up and down/ET CO2.

The bougie may become your best friend. Especially if you dont intubate all the time.

 

[signomi]

Interesting. Do you think trying it out on a mannequin would be beneficial?

 

[jetproppilot]

Interesting. Do you think trying it out on a mannequin would be beneficial?

Can't hurt.

But next time you see something familiar upon laryngoscopy but cant quite steer in the ETT, think bougie.

And more importantly, make sure they are stocked in areas where you'll need them.

 

[signomi]

Right now I am trying to see about getting miller blades in every crash cart and getting pancuronium on the floors (it's only in ICU!). What's one more request?
ETA: If you get the bougie in, could I run across the same problem I had with the ET tube? Where it wouldn't make the turn in the oropharynx? How do you manipulate it?

 

[jetproppilot]

Right now I am trying to see about getting miller blades in every crash cart and getting pancuronium on the floors (it's only in ICU!). What's one more request?

I think succinylcholine would be a better choice (over pancuronium), Sig.

You can give a very small dose (40-60 mg....2-3mL) which gives you paralysis for a cuppla minutes...and if things go awry it wears off.

I've been in private practice ten years and I've never given pancuronium for an intubation on the floor.

Use sux.

Just remember not to give it to

1)burn patients
2)lower-motor-neuron-injury paients...i.e. spinal cord injury
3)someone whos been in bed for over a month or so
4) someone with a really high K+ (like over 5.5)
5) someone with a muscle disease

the majority of patients you intubate will be MI/CHF/COPD patients so the above won't be a worry most of the time...but review the chart before you give sux...

if you dont see any contraindications, give 2-3 mL IV. Mask ventilate.

And give some midazolam (2-5 mg) before all this if you can to buzz them out so they dont remember the tube.

 

[signomi]

Unfortunately they only stock pancuronium in most carts. Some have succs, but I have had 2 intubations prior to this that had those contraindications. The other problematic area is that I really can't read the chart. I am the only doc in the entire hospital except one ED doc that doesn't come to codes. So the code team is me and 2-3 nurses and an RT. I'm lucky if the nurse can answer half of my patient related questions.
Think itty bitty little community religious hospital in the burbs. I've been told codes are rare, but I am running 3 for 6 shifts!

 

[Anesthesia1979]

a few other quick points that I'm sure you already realize.. even though she had a PEG there is actually increased risk of aspiration if she were to survive the code....

a thought if you can't get the mouth open or get a view of the cords or even get an LMA in, then there's always a blind nasal intubation...

glad to hear you mention the LMA though... even happier that a cric wasn't attempted.

also the timing of onset for pancuronium is a couple of minutes where the sch will come on in less than a minute.

 

[signomi]

What do you use for the blind nasal intubation? I was asking one of my partners about a nasal tool...and he went straight to cric. He recently took a class and I think he is gunning to use it. Whereas I am:

I am sure she aspirated as the original cause of the code. She was in for her umpteenth aspiration pneumonia admit.

 

[jetproppilot]

Unfortunately they only stock pancuronium in most carts. Some have succs, but I have had 2 intubations prior to this that had those contraindications. The other problematic area is that I really can't read the chart. I am the only doc in the entire hospital except one ED doc that doesn't come to codes. So the code team is me and 2-3 nurses and an RT. I'm lucky if the nurse can answer half of my patient related questions.
Think itty bitty little community religious hospital in the burbs. I've been told codes are rare, but I am running 3 for 6 shifts!

OK.

So you've gotta use pancuronium.

Hey, gotta use whats available.

But you gotta make sure you dont burn any bridges commensurate with your airway-skill level.

See, Dude, giving pancuronium means patient-dude ain't gonna breathe on his own for quite a while.....and even in the anesthesiologists arena (airway), when you're talking about trying to stick a tube through the cords in an uncontrolled environment (i.e. on the floor/ICU/etc) , giving a muscle relaxant that isnt gonna wear off acutely brings risk.

That being said, I've been called for floor/ICU intubations where I've looked at the patient, assessed the situation, and blasted a stick of vecuronium (10 mg) in.....but then again, I intubate every day. Not saying that arrogantly. Take a monkey and let him do a task every day for ten years and he's gonna get pretty good at it.....

Point being is that if you're commanded to perform a task that you don't perform every day , then you've gotta think about the burning bridges rhetoric.

Guess I'm trying to convey to you that if I were in your shoes I'd think long and hard about the pancuronium thing....and if panc is available and sux isnt, well, time to talk to the powers-at-be and make sux available....its cheap so money isnt the issue....and again, it should be rare that you cant use it.....

....and if a contraindication to succinylcholine exists, give midazolam in 2mg increments until the patient is very somnulent....then take a quasi awake look ....if you cant get the tube in and the patient is hypoventilating, you can always give flumazanil to reverse the benzo acutely....no such reversal exists (at least not yet) for non-depolarizing muscle relaxants.....

gotta start thinking a step ahead....giving pancuronium for an urgent intubation makes you powerless if you can't get the tube in.....

 

[Anesthesia1979]

ideal is to have ET tube in warm water for a few minutes, then afrin to the nares for a few minutes... maybe use some nasal trumpets to "dilate the airway"... then feed the tube straight down then nares and the tube usually takes a liking straight towards the cords...

in a code?? ET tube with lots of lube and try and have someone auscultating on the other side away from chest compressions...

you can still be masking duing the insertion which shouldn't take long

Also they may have been talking about McGill's to grasp the tube and help guide it but won't help if patient can't open mouth...

Also crics that I've seen done... if not done on small old lady/man by someone that is truly experienced, they get bloody/ugly and never a good outcome.

 

[UTSouthwestern]

A couple of points: A bougie can be felt to bounce off the tracheal rings as it is advanced whereas an esophageal placement will feel smooth only.

In this circumstance, a nasal fiberoptic would likely have been your best bet given all of the oral/cervical pathology this patient has. Given your situation, it seems that this would likely not have been available.

A cheaper alternative that your hospital could invest in is a light wand for blind intubations, including nasals.

 

[dhb]

There is no in-house night time anesthesiologist. Question: how do you verify bougie placement?

If the bougie is in the trachea then you should be able to feel the cartilageous rings when the tip is pushed down.

 

[militarymd]

light wand....my favorite in this type of patient....atraumatic, fast, and everyone thinks its cool when they watch you use it.

 

[Gern Blansten]

Agree with the light wand sentiment. If the hospital won't stock them, you can bring your own. You could even carry it in a ...gulp...fanny pack.

 

[signomi]

Anything but the fanny pack!

 

[TabesDorsalis]

All of the responders to your post have given you excellent input that takes many of us years to learn in the O.R. The big lesson is that you need to update your crash cart. If your institution has a pt simulator, take an afternoon to learn how to use it and take other internists with you. Also, learn how to mask-bag a pt (the correct way). In my opinion this is more of an art than slamming a tube down a trachea. It is vital to know and the skill will come in handy one day... it's only a matter of time. And whatever you do, avoid the pancuronium on a crash and stick with sux unless contraindicated.

good luck

 

[HomerSimpson]

I have a question I need help with. I am an internist that runs the code team at night when I work. The other night I was called to a code. The patient was 87 and had Parkinson's disease and dementia. She had a PEG and hadn't eaten in years, also she was non-verbal. Let's say her jaw didn't see any use. I never got a straight answer as to why her jaw was frozen one inch open.
I could get the scope in, but her head was stuck in flexion, so there was no chance of extending her neck. Her teeth were all broken and sharp so I was ripping open my fingers trying to force her jaw open. Several people tried, but this was apparently a problem before the code. I even hit her with pancuronium to see if we could loosen it up. Nope. There was zero chance of seeing the cords. I tried blind insertion and probably because of her permanent shoulder and neck flexion, it went nowhere (it was 7.0). I tried the 4.0 LMA...and it didn't even fit between her teeth. We had to bag her during the code. She stayed in asystole for 35 minutes, so we called it.

So, my question, short of cricothyroidotomy, what were my options? Those are the only two pieces of equipment this small hospital carries. Are there any nasal tubes you have had success with? The hospital might be persuaded to purchase a third line option for these kind of cases.

And before someone asks, no it wasn't rigor mortis, it was a witnessed arrest.

Lots of great suggestions. The only thing I could add that hasn't been mentiioned is a retrograde intubation. In this case a cricothyroidectomy seems like a distinct possibility. So begin the process by cannulating the crycoid membrane. Pass the wire up(usually goes through the nose) If the patient becomes unstable proceed with the crycothyroidectomy if not then seldinger the tube in there. reinforced works better than regular but use what you got.

 

[nimbus]

Off topic, but....

Your hospital also needs to designate a code status on admission for all patients. Why code a demented 87 year old who hasn't eaten in years? We all know the outcome of a "successful" resuscitation for this lady. Anybody want this for themselves?

 

[Laryngospasm]

I have a question I need help with. I am an internist that runs the code team at night when I work. The other night I was called to a code. The patient was 87 and had Parkinson's disease and dementia. She had a PEG and hadn't eaten in years, also she was non-verbal. Let's say her jaw didn't see any use. I never got a straight answer as to why her jaw was frozen one inch open.
I could get the scope in, but her head was stuck in flexion, so there was no chance of extending her neck. Her teeth were all broken and sharp so I was ripping open my fingers trying to force her jaw open. Several people tried, but this was apparently a problem before the code. I even hit her with pancuronium to see if we could loosen it up. Nope. There was zero chance of seeing the cords. I tried blind insertion and probably because of her permanent shoulder and neck flexion, it went nowhere (it was 7.0). I tried the 4.0 LMA...and it didn't even fit between her teeth. We had to bag her during the code. She stayed in asystole for 35 minutes, so we called it.

So, my question, short of cricothyroidotomy, what were my options? Those are the only two pieces of equipment this small hospital carries. Are there any nasal tubes you have had success with? The hospital might be persuaded to purchase a third line option for these kind of cases.

And before someone asks, no it wasn't rigor mortis, it was a witnessed arrest.

Pancuronium has no business anywhere near an emergency airway. Also it is very helpful for blind nasals to be SPONTANEOUSLY breathing. I thought the pancuronium thing was a joke initially. Did you deflate the LMA and it still didnt fit through the teeth? It should have if her mouth was stuck an inch open. Why the hell wasnt the patient DNR anyway

 

[signomi]

Yes the LMA was deflated and it didn't fit.
And the DNR thing is really frosting my cookies. I am not the admit doc for any patients. It is up to the admit docs to address code status and it just isn't getting done. I have been stunned by the people I see that are full code. I had heard PCPs were bad about addressing it and never believed it fully until now.
I am going to look into getting succ available on all carts.
Thanks to everyone for the advice!

 

[Laryngospasm]

Yes the LMA was deflated and it didn't fit.
And the DNR thing is really frosting my cookies. I am not the admit doc for any patients. It is up to the admit docs to address code status and it just isn't getting done. I have been stunned by the people I see that are full code. I had heard PCPs were bad about addressing it and never believed it fully until now.
I am going to look into getting succ available on all carts.
Thanks to everyone for the advice!

Just make sure to understand the potassium issue with sux, ideally you would have sux and a short acting non-depolarizer, roc with the new roc binding agent when available would be ideal if a little expensive.

 

[meddog1]

Just make sure to understand the potassium issue with sux, ideally you would have sux and a short acting non-depolarizer, roc with the new roc binding agent when available would be ideal if a little expensive.

Yeah, if the pt was bed-ridden for some period with the Parkinson's, sux could create a hyperkalemic picture.

 

[Annette]

It is up to the admit docs to address code status and it just isn't getting done. I have been stunned by the people I see that are full code. I had heard PCPs were bad about addressing it and never believed it fully until now.

At my (ex) hospital, the admitting clerks were supposed to ask every patient about advance directives and living will. Guess which box always got marked? Pt has no interest at this time. When I asked, patients almost always had at least thought about it, and the vast majority wanted more information.

 

[ReefTiger]

I'm obviously late in joining in on this thread, but I felt I could offer some advice for future readers. There is obviously no need for me to talk ad nauseum about how fast things go bad in an airway situation--especially oustside the OR. Based on this I'll reiterate what's been said before, because it is worth reading again, and offer some new tactics.

First is what should be in your crash cart/airway cart:

#1 You should make sure you have all four (MAC 3, 4 and Miller 2, 3) blades with two laryngoscope handles one short length, one standard length

#2 Have size 6 through 8 ETT with at least one stylet.

#3 Have size 3-5 LMAs

#4 A bougie/eschmann's stylet (If you have never used one it is easy. Make sure the hockey stick end goes towards the patient, and the tip of the stick faces anteriorly. This way once you're past the cords you feel the anterior tracheal rings--remember only the cricoid has a ring posteriorly.)

#5 different sizes of oral airways (most people use 90mm) and nasal trumpets

I also strongly agree that Pancuronium is not a good choice. I understand if it's all you've got, but I would only give that drug if I knew I could control the airway. I understand hindsight is 20/20, but I would have approached the situation like this. Also, I'll let you know I make sure I am overly paranoid outside the OR, and am totally prepared before starting. I'll explain what I mean.

At bedside-rapid assessment of pt. Get two different blades ready (one on each handle). have LMA ready and have bougie available. Drugs should be drawn up. Suction available/working. I would induce the patient but not paralyze. Once patient is induced attempt to mask ventilate. Use oral/nasal airway if necessary. If you can mask ventilate you are golden. Then you can use a long acting agent like panc safely. If not use sux or rocuronium.

Try to intubate with the blade you feel most comfortable with first. If you can't get the intubation assess your problem and on the second attempt DO SOMETHING DIFFERENT--diff blade, bougie, LMA etc. Mask ventilate in between attempts if possible. Always try to get help. Four hands are better than two.

No one wants to do an emergency airway/cric, but it does save lives.

One last thing, which may have been useful in a situation like this. You can mix propofol and ketamine in a single syringe. Prior to titrating this into the patient spray cetacaine topical into the oropharynx. You can then slowly titrate the "ketofol" to a point where the patient remains spontaneously breathing, but is sedated. Then, while talking/reassuring the patient ("Mr/Mrs X I'm going to take a look in your mouth gently") you can actually perform direct laryngoscopy. I couldn't believe it the first time I did it, but if the OP is numbed patients tolerate this technique well.

You use this to try to assess how difficult the airway may be. You obviously would give them a full induction and paralyze them prior to your intubation attempt.

Sorry about the length, but hope it helps someone.

 

[mille125]

sux is not a good option in a bedridden patient. hyperkalemia would likely occur...in this situation it probably wouldnt matter. However, remember, bedridden, immobilized patient can have a severe hyperkalemic response.

 

[Planktonmd]

The one skill that everyone who participate in a code should know is how to properly mask ventilate!
In my experience 90% of non anesthesia trained providers don't know how to properly hold a mask and that includes EMS, respiratory therapists and ICU nurses.
So if you really want to improve your chances of saving lives, you need to go to your friendly anesthesiologist and ask him to show you how to hold a mask.