as jwk put it.. "As many find out eventually, you never regret putting in a tube, but at some point you will regret not putting one in."
I'm happy to see a variety of answers. Here is what played out...
For reasons unclear to me, we were proceeding with this case last night at 21:30 instead of rolling it over to the morning. I don't believe it was classified as an emergency, i.e. it was not an open fracture. I think ortho had a busy day yesterday and it was carried over from the day's add-on schedule. I mean, he was NPO, right?
Junior resident is out in holding doing the pre-op assessment, discussing case with our attending, who btw is one of our good guys - trustworthy, smart, great skills, etc. My gut tells me RSI and tube, if only because it's a "trauma", and our ortho boys usually ask for "zero twitches", for the most ridiculously simple cases. However, the attending and other resident had discussed GA with LMA, and we proceed to the OR, induce with propofol, LMA #5 in without problem. Sevoflurane on, pt breathing. Ortho boys scrubbing and prepping.
Attending is out to holding seeing our next ortho case. About 5 minutes after LMA placement, I turn around from drawing up drugs for the next case, and at the same time hear junior resident say "oh $hit", and I see copious vomit coming up through the LMA into the circuit. Not bile, but chunky oatmeal-looking vomit. 300 cc easy. I place the SOS call to attending - "Here. Now. Vomit." Within the next few seconds, he is in the room, LMA has been removed, suctioning oropharnyx, and ETT 8.0 goes in under DL. Bronchoscopy by us. Whistle-tip catheter suctioning through ETT reveals a large amount of vomit. Irrigation with saline until the suction runs clear. Intra-op pulmonary consult, formal bronchoscopy by the pulmonary/CCM attending.
Pulmonary/CCM attending is impressed with how clear the lungs sound and look after bronchoscopy, thinks we might have dodged a bullet and thinks we might be able to extubate. We attempt, but he is unable to maintain sats >85 in PACU and gets reintubated (with significant airway edema now), buys himself an art line, cent line and trip to the unit.
CXR immediately post-op shows significant white out on left compared to pre-op. One hour post-op shows worsening infiltrates on the right now as well.
Going to check up on him tomorrow.
Our first thought was "this guy clearly lied and had eaten". We questioned his wife who swore she was with him, and he was NPO. So was it gastroparesis from trauma? Narcotics in the ED? My attending said it was the worst vomiting he had seen in 18 years of practice.
In retrospect I wish I had pushed for an ETT, but I can't say an LMA was a clearly wrong choice. More importantly, we should have just left him intubated instead of the trial of extubation. Attdg was kicking himself the rest of the night, and I was just happy to see that now instead of "Day One" as an attending myself...