Questions about a difficult airway.

[prettyNURSEtoMD]

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Hi guys. I'm an RN at a level 1 ED. I just wanted some feedback because I'm quite curious on how others would have handled this intubation. I had a PT who came in for AMS. Husband went to wake up this morning unresponsive. Hx of CVA no deficits. And recently had a valve replaced due to leakage and a CABG. CT showed Subdural hematoma with a midline shift. GCS 8 Trauma Score of 9. They ended up activating trauma I'm not sure why because it was presumed that she did not have a traumatic fall within the last 48 hours. But nevertheless trauma came. 2nd year surgery resident attempted to Intubate no success after 2-3 times and with and without a glidescope. So we bag her, my attending comes, no success and she used a bougie and a glidescope too, nothing. Trauma attending steps in uses a Mac and a miller and nothing. So approximately 40 minutes has gone by. They call the CRNA to say they have a difficult airway and if she could use a fiberoptic. It takes about 10-12 mins for her to get to the ED. She doesn't have a fiberoptic but she does have some degree of difficulty but after about 7 mins she's in with a 7.0 ETT 23 at the teeth using a miller. So my question is what is your sequence of events with a difficult airway. When would you do a surgical airway? Thanks guys!

 

[NYEMMED]

Hi guys. I'm an RN at a level 1 ED. I just wanted some feedback because I'm quite curious on how others would have handled this intubation. I had a PT who came in for AMS. Husband went to wake up this morning unresponsive. Hx of CVA no deficits. And recently had a valve replaced due to leakage and a CABG. CT showed Subdural hematoma with a midline shift. GCS 8 Trauma Score of 9. They ended up activating trauma I'm not sure why because it was presumed that she did not have a traumatic fall within the last 48 hours. But nevertheless trauma came. 2nd year surgery resident attempted to Intubate no success after 2-3 times and with and without a glidescope. So we bag her, my attending comes, no success and she used a bougie and a glidescope too, nothing. Trauma attending steps in uses a Mac and a miller and nothing. So approximately 40 minutes has gone by. They call the CRNA to say they have a difficult airway and if she could use a fiberoptic. It takes about 10-12 mins for her to get to the ED. She doesn't have a fiberoptic but she does have some degree of difficulty but after about 7 mins she's in with a 7.0 ETT 23 at the teeth using a miller. So my question is what is your sequence of events with a difficult airway. When would you do a surgical airway? Thanks guys!

Was the pt bagable? If Postive pressure ventilation wasnt able to be adequately provided then I wouldnt have waited close to an hour. But if the pt was able to be ventilated during this you theoretically have time. Usually at my ED if the resident cannot drop a tube by the third try, the attending gives it a shot. Anesthesia should be called before the ED attending tries, if they arent there yet then straight to surgical airway.

 

[prettyNURSEtoMD]

She was baggage. Her sats maintained 100% the entire time. She did start to wake up of course so we gave 20 more of etomidate (the 40 total). Then surely attending wanted 10 of vecuronium....and he tried. It was just making me anxious lol like geez...I'm just a little premed though so I'm just looking I'm awe like what would I do haha. Thanks for the feedback

 

[B-Bone]

http://ether.stanford.edu/difficult_airway.html

for ED patients, remove the "wake pt up" option

 

[prettyNURSEtoMD]

Baggable* not baggage lol

 

[prettyNURSEtoMD]

Thank you for that website!

 

[Hamhock]

iLMA

HH

 

[Bostonredsox]

Why did they fail? unfavorable anatomy? inability to place head in sniff vs extension? tracheal stenosis? visualization?

this guy has a brain bleed with shift and is headed to the OR and a long recovery in SICU if he survives. If they couldnt see the cords witha glide, and could not pass a bougie blindly, I would move right to surgical airway. He is ventilating well. Place LMA. Sedate. perc Trach at bedside.

There is a good chance he will end up trached in SICU anyway based on his recovery time on the ventilator. Dont fuk around. If you cant get in with a glide or a bougie in experienced hands in a trauma pt, trach them. At least thats what I would have done.

 

[dotcb]

resident: 2-3 attempts

me: 2-3 attempts

as long as the patient can be ventilated
(while we try to identify the barrier to success and make changes each look to optimize our attempts)

No success? call anesthesia while either bagging or placing an LMA.

If can't ventilate or oxygenate at any point - surgical airway

In the case described the patient did not require surgical airway because they were well oxygenated and ventilated. Next options would be fiberoptic intubation through LMA or elective surgical airway.

 

[Bostonredsox]

resident: 2-3 attempts

me: 2-3 attempts

as long as the patient can be ventilated
(while we try to identify the barrier to success and make changes each look to optimize our attempts)

No success? call anesthesia while either bagging or placing an LMA.

If can't ventilate or oxygenate at any point - surgical airway

In the case described the patient did not require surgical airway because they were well oxygenated and ventilated. Next options would be fiberoptic intubation through LMA or elective surgical airway.

Although he is ventilating well, he needs to go to the OR so he needs to be tubed. After attending failed with glide I agree, call for gas to attempt fiber optic. In this case she said fiber optic wasn't an option. Thus I would have proceeded to elective surgical airway, LMA + perc trach.

 

[e30ftw]

sounds like there were too many people in the airway before anesthesia got called..

it's difficult to really say what went wrong without knowing the patient's airway anatomy, each doc's laryngoscopy skills, etc. if the ED attending couldn't get the tube with a bougie and a glidescope, anesthesia should have been called and the patient should be ventilated by whatever means necessary until arrival. if the patient cannot be ventilated a surgical airway should be obtained.

40 min sounds like a long time and honestly in the ED I don't think I've ever seen an impending airway wait that long without getting tubed/cric'd but if they had no problem bagging it's not unreasonable imo. Having to resort to a surgical airway after attempting induced endotracheal intubation is kind of a "fail' and if the patient is being ventilated well it probably involves less risk to the patient than cutting a hole in the guys neck anyway..

a resident colleague told me a story of intubating a pt while moonlighting at an outside hospital and the only vent in the ED broke and the pt had to be bagged for like 2 hours waiting for transport. that's a long time..

 

[Spinach Dip]

a resident colleague told me a story of intubating a pt while moonlighting at an outside hospital and the only vent in the ED broke and the pt had to be bagged for like 2 hours waiting for transport. that's a long time..

That's a lot of nurses and aides with impending hand cramps.

 

[goodoldalky]

There is no such thing as an "elective surgical airway" in the ED, whatever that is. Can't intubate, can't ventilate, then surgical airway. That's the only time you do it.

 

[prettyNURSEtoMD]

Double post. Sorry.

 

[prettyNURSEtoMD]

When CRNA placed the tube we called for a portable chest and the trauma attending said to my attending "hey you've got to see this". So my nosey self hops up too, and they both say "that's why" she had some weird curvature. I can't tell you what it's called but they said a word. And my attending kept saying " her (.....) were so acute" I cannot think of the word. I'm sorry. Trauma then wanted an NG or OG...we could not get it. At all. Neurosurgery came to evaluate. INR was only 2.4. PFA was 93. She ended up getting FFP, Cerebyx, Vit K and Mannitol. He said that if she starts to improve he will operate if not then he wouldn't....I can assume the outcome but she went to ICU. On no sedative. No activity. Thank you all for your responses. I learned so much! 🙂

 

[dotcb]

There is no such thing as an "elective surgical airway" in the ED, whatever that is. Can't intubate, can't ventilate, then surgical airway. That's the only time you do it.

Not true - massive facial trauma w/ extensive bleeding in face & airway - can't intubate, ventilating fine at the moment.

You elect to do surgical airway.

Same w/ worsening angioedema patient who you can't intubate but is currently ventilating fine.

Really - it depends on your setting. In my hospital there's in-house anestheria and surgery, so I'm only doing a cric if it's a crash situation. But if you're in a solo coverage ED, I might cric a patient who needed it urgently before I have someone drive in from home call. If the patient was enormous and stable I would certainly call for help.

 

[gro2001]

Not true - massive facial trauma w/ extensive bleeding in face & airway - can't intubate, ventilating fine at the moment.

You elect to do surgical airway.

Same w/ worsening angioedema patient who you can't intubate but is currently ventilating fine.

Really - it depends on your setting. In my hospital there's in-house anestheria and surgery, so I'm only doing a cric if it's a crash situation. But if you're in a solo coverage ED, I might cric a patient who needed it urgently before I have someone drive in from home call. If the patient was enormous and stable I would certainly call for help.

You are both right in a way. It's the weird distortion field of our specialty that when we have like 5 minutes to set up to intubate someone we think of it as almost an elective intubation. Anyone else would think its the most emergent thing in the world. What you are describing (worsening but stable for now angioedema, facial trauma requiring intubation but bagable) are EMERGENT situations. We see too many people who live or die based on critical actions within 2 minutes or less that when we encounter someone who would live an extra say 15-30 minutes without intervention we call it 'elective'. It's not an elective surgical airway unless they have been NPO, are consented, the site has been marked, patient prepped and draped, physician is gowned, imaging has been reviewed and surgical time out has been down (ie: not in the ER). We deal with emergencies.