Something I thought I'd never see

[pd4emergence]

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So this was a while back, finally get to the call room about 0230 for the second time, the first time I laid down for about five minutes and then got called for three epidurals in a row. Tempting the call gods again, I lay down and in about 5 minutes get a call. Me "hello", ER physician "hey we got this guy down here in respiratory distress and would like you to come look at him", Me "ok, be right down". I head out of the call room and immediately hear "respiratory to ED stat" and so I started walking a little faster. In the ed I find the ed doc, along with a respiratory therapist and a few nurses in the process of bagging what looks like a normal sized 30ish guy, sats are in the low 80's and they are fighting a losing battle. I look at the ed guy and he says this guy quit taking his dannazol about two weeks ago and now he is here. I say huh? The ed guy says "oh yeah I forgot to mention this guy has hereditary angioedema and has been struggling for a while, we tried epi and steriods earlier but it didn't work".

 

[Arch Guillotti]

At least you didn't get the call at the smae time you had 3 epidurals and a stat c/s.

Depending on how big his tongue was/airway exam, probably awake nasal FOI.

 

[Jay K]

I look at the ed guy and he says this guy quit taking his dannazol about two weeks ago and now he is here. I say huh? The ed guy says "oh yeah I forgot to mention this guy has hereditary angioedema and has been struggling for a while, we tried epi and steriods earlier but it didn't work".

Of course you just pulled out your fiberoptic with tower and big screen out of your back pocket and said no problem! I remember this BS in residency when called on the phone to an "airway look," arrive, then am greeted with the "Where's your fiberoptic?" "Oh sure, it's in my back pocket..." Sorry you got this BS pulled on you without the proper forewarning/info.

 

[ssmallz]

So this was a while back, finally get to the call room about 0230 for the second time, the first time I laid down for about five minutes and then got called for three epidurals in a row. Tempting the call gods again, I lay down and in about 5 minutes get a call. Me "hello", ER physician "hey we got this guy down here in respiratory distress and would like you to come look at him", Me "ok, be right down". I head out of the call room and immediately hear "respiratory to ED stat" and so I started walking a little faster. In the ed I find the ed doc, along with a respiratory therapist and a few nurses in the process of bagging what looks like a normal sized 30ish guy, sats are in the low 80's and they are fighting a losing battle. I look at the ed guy and he says this guy quit taking his dannazol about two weeks ago and now he is here. I say huh? The ed guy says "oh yeah I forgot to mention this guy has hereditary angioedema and has been struggling for a while, we tried epi and steriods earlier but it didn't work".

Sounds like standard ED BS to me

 

[urge]

did you trach him?

 

[IN2B8R]

did you trach him?

Dude, I dig your replies/questions. But to answer your question, no, no trach: a magic wand from the ass pocket of the scrubs was waived over the patient's AW and he was magically healed 😛

 

[IlDestriero]

I used to keep a bougie down my pants, just for this kind of thing.

 

[SleepIsGood]

Hopefully your ER has an "emergency a/w" cart of some sort. Ours now does..fully equipped with even a glidescope!

 

[pd4emergence]

Pt was being bagged with sats dropping, no real time to go to the OR, and no time to call anybody else. The ed does have an airway cart. It was already there, no glidescope though. Actually, this was before widespread glidescope use at our place. Now we have 4 of them for the ORs, the ED has one and our ICU has one.

What next?

 

[Planktonmd]

Pt was being bagged with sats dropping, no real time to go to the OR, and no time to call anybody else. The ed does have an airway cart. It was already there, no glidescope though. Actually, this was before widespread glidescope use at our place. Now we have 4 of them for the ORs, the ED has one and our ICU has one.

What next?

Spray the mouth and pharynx with topical anesthetic (maybe benzocaine), inject transtracheal Lidocaine 4%, and say: Sir, this is not going to be pleasant but you have to help me out, ask him to open his mouth as wide as he can, then slide your Mac 4 blade in and intubte the guy.

 

[Surfer]

do not use a glidescope. this guy has hereditary angioedema and any attempts at monkeying the airway are only going to make it worse. the edema has already compromised his airway so i have doubts you'll see anything no matter what airway technique you use. so go straight to your big gun... the way i see it, you get one chance with an awake fiberoptic. topicalize the airway with nebulized 4% lidocaine while he preoxygenates. give him some lido jelly to suck on to get the back of his tongue. this will only take 2-3 minutes. give him a little robinol and some versed. now take a look with the fiberoptic. if you see the chords, go for it... once you're past the chords see if you can pass the tube in (might be impossible if he's too tight). if the tube passes give him propofol, secure the tube, and strut out of there like the hero you are.

BUT: if you can't see shee-it, you're in trouble. you can try to get the fiberoptic to magically end up in the trachea, but good luck with that. more than likely you're going to end up doing an emergent, awake trach. Have the surgeons use lots of local and tell them to hurry so you don't have to do CPR on the guy.

 

[pd4emergence]

I have had a few people come in with angioedema. One I did a fiberoptic on, his airway wasn't that bad, tongue wasn't huge but his lips were pretty big and things werent getting better. Had another where the guys tongue was huge, lips were big, everything was edematous, looked for about 10 seconds with a fiberoptic but just wasn't going to get anywhere with it. Ended up doing an awake glidescope with the ent standing by with a scapel. Both of the above were ACE I induced. I also had some time with these two.

With this guy, I tried to spray him down but he was uncooperative and would not open his mouth. Not even a little bit. He is basically totally obstructed. Sats are now 60's and bagging him is totally ineffective. Cric kit was sitting by the bedside.

 

[urge]

So you trached him?

I ask because I think they called you too late. This guy does not need positive pressure ventilation. He needs a patent airway. He is too far down the hole to mess around with a fiberoptic.

 

[Mista Suprane]

topicalize the airway with nebulized 4% lidocaine while he preoxygenates. give him some lido jelly to suck on to get the back of his tongue. this will only take 2-3 minutes.

preoxygenates? did i miss something or is he an unsuccessful mask with sats in the 80s? i don't think you have 2-3 minutes.

i think it's quick and dirty topicalization (30 sec), a quick look (30sec) with oral fiberoptic while simultaneously finding someone else who can start prepping the neck.

 

[pd4emergence]

Here is what happened. Sat's continued to drop. What little I could see of his airway, his lips were a little edematous, tongue was not in the way but he was not going to let me put in a blade. I had the ER folks prep the neck but I really wanted to take a look. He was totally obstructed and this was not going to get any better. I felt that pushing drugs was not going to make the situation worse. We were going to be coding him soon anyways and I was going to be performing my first cric. Cric kit ready, Bougie was ready, 10 mg Etomidate given, pt still would not relax, 100 mg sux given and I was able to get a blade in (mac 3). As I said tongue was not terribly edematous, I was able to visualize a very edematous epiglottis, and was able to lift it up some, I passed a bougie under it and in between an edematous area with a break in the middle and a few bubbles coming from this area, bougie went easily and felt good and I was able to pass a tube. Bilateral breath sounds and etco2 confirmed, sats got better. I wrote my note, kicked the ER attending in the balls and went back to bed.

Would you have handled this differently?

 

[Surfer]

wow, good work! here's a question for you though... is there any concern that even after getting the tube in, you could have sufficient edema to clamp your tube closed? I know this has happened in other circumstances that i have read about... I guess you'd have some warning of that impending doom, but i also think a surgical airway in this patient would have been totally appropriate.

i would not feel totally comfortable doing the surgical airway myself, so i might have tried what you tried. why didn't you take a look with the fiberoptic?

 

[Licoricestick]

Here is what happened. Sat's continued to drop. What little I could see of his airway, his lips were a little edematous, tongue was not in the way but he was not going to let me put in a blade. I had the ER folks prep the neck but I really wanted to take a look. He was totally obstructed and this was not going to get any better. I felt that pushing drugs was not going to make the situation worse. We were going to be coding him soon anyways and I was going to be performing my first cric. Cric kit ready, Bougie was ready, 10 mg Etomidate given, pt still would not relax, 100 mg sux given and I was able to get a blade in (mac 3). As I said tongue was not terribly edematous, I was able to visualize a very edematous epiglottis, and was able to lift it up some, I passed a bougie under it and in between an edematous area with a break in the middle and a few bubbles coming from this area, bougie went easily and felt good and I was able to pass a tube. Bilateral breath sounds and etco2 confirmed, sats got better. I wrote my note, kicked the ER attending in the balls and went back to bed.

Would you have handled this differently?

I think if you're presented with a dire situation like this then anything that restores a patent airway quickly is the right answer. The only potential problem with your approach might have been if you didn't have a view and got tunnel vision, leading to persisting with laryngoscopy, rather than cutting the neck. Obviously that wasn't the case.

Nice job!

Maybe you could have kicked the ER attending twice...but that might have been a waste of an extra few seconds you could have spent in bed.

 

[pd4emergence]

wow, good work! here's a question for you though... is there any concern that even after getting the tube in, you could have sufficient edema to clamp your tube closed? I know this has happened in other circumstances that i have read about... I guess you'd have some warning of that impending doom, but i also think a surgical airway in this patient would have been totally appropriate.

i would not feel totally comfortable doing the surgical airway myself, so i might have tried what you tried. why didn't you take a look with the fiberoptic?

I think that edema clamping off a tube usually happens with smaller diameter tubes. I was able to corkscrew a 7.0 in this guy. Once I got past his laryngeal edema the tube fit pretty easily. I agree with you that that is a concern but I felt like at least trying to put a tube in was worth a shot.

I'll be honest, most fiberoptics except the very routine one, would have taken me more time than I had here. I figured I would get one try before I was going to have to cric this guy. As an aside, from now on in these pt's I feel that an awake glidescope is the way to go. I think the anatomy is so distorted that the narrow view that the fiber gives you is a detriment. At least with the glidescope you can get some idea of where you are b/c of the added advantage of being able to see where the blade is going. I did not have a glidescope here and probably would have had to still push drugs to even get the blade in.

 

[cchoukal]

I was really interested in the point about how, because the patient had already completely obstructed, you weren't going to make anything worse by inducing. I'm not sure how that would play out in an M and M or a trial, but it makes sense to me. I think that would've been a really tough call to make in the moment, but it seems like a good point to consider in your decision tree; I probably will.