Unanticipated airway

[proman]

Wanted to get the hive's opinion on this:

Emergency case in a remote anesthesia location, middle aged patient is NPO. History significant for morbid obesity, HTN, active smoking. Airway exam: TM 4 fingers, oral excursion 2 1/2, MP IV, full range of motion. Attending, 2 senior residents present. The case requires ETT.

Monitors, pre-oxygenate, induce with propofol. Grade 3 mask ventilate (2 hands, oral airway). Quickly becomes Grade 4 (unable to ventilate). LMA 3 placed with marginal but adequate TV, SpO2 stabilizes. Difficult airway cart 10 minutes away. What now?

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[smgilles]

Wanted to get the hive's opinion on this:

Emergency case in a remote anesthesia location, middle aged patient is NPO. History significant for morbid obesity, HTN, active smoking. Airway exam: TM 4 fingers, oral excursion 2 1/2, MP IV, full range of motion. Attending, 2 senior residents present. The case requires ETT.

Monitors, pre-oxygenate, induce with propofol. Grade 3 mask ventilate (2 hands, oral airway). Quickly becomes Grade 4 (unable to ventilate). LMA 3 placed with marginal but adequate TV, SpO2 stabilizes. Difficult airway cart 10 minutes away. What now?

Wake them up and do fiberoptic.....

 

[OB1🤙]

Wake his fluffy ass up while someone brings the cart and do an awake FOI.

Edit: beat me to it.

 

[IceDoc]

Wanted to get the hive's opinion on this:

Difficult airway cart 10 minutes away. What now?

Oops. How bad does an airway exam have to be before you gather the equipment beforehand? Was there a DL? Difficult mask does not necessarily mean difficult intubation. Given your scenario, the correct answer is to wake him up. The alternative is, if your LMA is well seated (i.e. you could give some PPV if necessary), then you can keep him spontaneously ventilating until you get plan C assembled. With the LMA in place, just throw in an aintree over a scope, remove LMA, slide ETT over aintree. Voila. Or maybe the LMA was an intubating LMA....but that wouldn't be much of a story would it.

 

[proman]

Oops. How bad does an airway exam have to be before you gather the equipment beforehand?

Apparently this bad. No spontaneous resp, sux was given after 2 handed mask was done.

We decided to do a DL while waiting for the airway cart, since we had a functioning airway as our backup. Grade 3 view, esophageal intubation. LMA 4 placed (upsized to allow easier placement of fiberoptic/Aintree). Can't ventilate. LMA 3 put back. Can't ventilate. Emergency airway response called for (gets trauma and ENT).

What next?

 

[Noyac]

Oops. How bad does an airway exam have to be before you gather the equipment beforehand? Was there a DL? Difficult mask does not necessarily mean difficult intubation. Given your scenario, the correct answer is to wake him up. The alternative is, if your LMA is well seated (i.e. you could give some PPV if necessary), then you can keep him spontaneously ventilating until you get plan C assembled. With the LMA in place, just throw in an aintree over a scope, remove LMA, slide ETT over aintree. Voila. Or maybe the LMA was an intubating LMA....but that wouldn't be much of a story would it.

Wouldn't these things be in the difficult airway cart which is 10 minutes away?



Personally, I think the real problem began when you guys entered the room. If you didn't notice the possibility of a difficult airway (I know you are a junior resident and your superiors should have noticed the airway) when you walked into the room, then you are not ready for the real world. You guys should have known you "might" need the difficult airway cart. But thats what residency is for. You will be fine but your attending may not be.

 

[fakin' the funk]

We decided to do a DL while waiting for the airway cart, since we had a functioning airway as our backup. Grade 3 view, esophageal intubation. LMA 4 placed (upsized to allow easier placement of fiberoptic/Aintree). Can't ventilate. LMA 3 put back. Can't ventilate. Emergency airway response called for (gets trauma and ENT).

This is my super, super junior response but...if you goose the 1st ETT on a clearly difficult airway, don't you just leave the tube there? If it's there you can Glidescope or DL another into what has to be the only other option - no? Though you'd need all that stuff immediately at hand d/t need to ventilate.

 

[toughlife]

Wanted to get the hive's opinion on this:

Emergency case in a remote anesthesia location, middle aged patient is NPO. History significant for morbid obesity, HTN, active smoking. Airway exam: TM 4 fingers, oral excursion 2 1/2, MP IV, full range of motion. Attending, 2 senior residents present. The case requires ETT.

Monitors, pre-oxygenate, induce with propofol. Grade 3 mask ventilate (2 hands, oral airway). Quickly becomes Grade 4 (unable to ventilate). LMA 3 placed with marginal but adequate TV, SpO2 stabilizes. Difficult airway cart 10 minutes away. What now?

What was the procedure/surgery?

 

[ProRealDoc]

Wanted to get the hive's opinion on this:

Emergency case in a remote anesthesia location, middle aged patient is NPO. History significant for morbid obesity, HTN, active smoking. Airway exam: TM 4 fingers, oral excursion 2 1/2, MP IV, full range of motion. Attending, 2 senior residents present. The case requires ETT.

Monitors, pre-oxygenate, induce with propofol. Grade 3 mask ventilate (2 hands, oral airway). Quickly becomes Grade 4 (unable to ventilate). LMA 3 placed with marginal but adequate TV, SpO2 stabilizes. Difficult airway cart 10 minutes away. What now?

what was the procedure/surgery?

 

[IceDoc]

Wouldn't these things be in the difficult airway cart which is 10 minutes away?

Note: I was implying that if you really had adequate ventilation with the LMA, then you could keep him spontaneously ventilating until that airway cart arrives. The problem with this approach is if something happens in the meantime, you're hosed. Aspiration, losing the seal, inadequate spontaneous ventilations etc... That's why the correct answer was still to wake him up.

And I agree with the remainder of the post. The key learning point is that as an attending, you need to be focused on what will get you in trouble. Marginal airway in remote location...recipe for an O.S. moment.

Fortunately, the more you practice, the more quickly and accurately you assess what will get you in trouble (without becoming an obstructionist tool).

 

[UTSouthwestern]

Heine blade, fiberoptic through the LMA, combitube, etc., however, preparation is the key. Having the cart there before you induce is the key and being comfortable doing an emergency cric doesn't hurt.

 

[9french]

Apparently this bad. No spontaneous resp, sux was given after 2 handed mask was done.

We decided to do a DL while waiting for the airway cart, since we had a functioning airway as our backup. Grade 3 view, esophageal intubation. LMA 4 placed (upsized to allow easier placement of fiberoptic/Aintree). Can't ventilate. LMA 3 put back. Can't ventilate. Emergency airway response called for (gets trauma and ENT).

What next?

You can't intubate, can't ventilate, you are out of normal options and help is 10 minutes away? I'm assuming that there is no jet ventilator around. Assuming a scalpel, or even at this point a pocket knife, can be found, you need to do an emergency cric. Patient is dead anyway; Only thing you can do is save her.

By the way, as soon as you realized you were in a bad situation, but could ventilate, you should have waked the patient up.

 

[SleepIsGood]

Why do you guys think tht the OP couldnt ventilate this pt the second time around?

He was obviously able to ventilate with a LMA 3 at one point before the paralytic. Perhaps soft tissue collapse? But if it were soft tissue collapse, I dont see how a LMA 4 wouldnt be able to 'displace' the soft tisue and allow him to ventilate. One could be concerned about laryngospasm, but that's impossible since he paralyzed the patient.

In my mind I'm just trying to figure out a scenario where a patient is paralyzed and you couldnt ventilate someone where there's a device sitting right above the cords.


perhaps bronchospasm or some other 'lower' airway issue? A floppy epiglottis or some tumor right in front of the cords?

 

[BobBarker]

At the medical center I just rotated at they had a standard and small Airtraq on every cart. It worked flawlessly on a 600 lb patient.

 

[DET0897]

Wanted to get the hive's opinion on this:

Emergency case in a remote anesthesia location, middle aged patient is NPO. History significant for morbid obesity, HTN, active smoking. Airway exam: TM 4 fingers, oral excursion 2 1/2, MP IV, full range of motion. Attending, 2 senior residents present. The case requires ETT.

Monitors, pre-oxygenate, induce with propofol. Grade 3 mask ventilate (2 hands, oral airway). Quickly becomes Grade 4 (unable to ventilate). LMA 3 placed with marginal but adequate TV, SpO2 stabilizes. Difficult airway cart 10 minutes away. What now?

Why not take a quick look after you lost the ability to vent but before you gave paralytics. If looks ok, give the sux and tube. If not, then put in your LMA, which apparently worked the first time. Keep the LMA in until a) cart arrives or b) patient wakes and start over. Not sure why you pulled out a working LMA to then take a look/DL when you had not done anything to improve your situation. If you had looked before hand, you need not have pulled the working LMA. Now you are screwed, when really screwed try this:

1. Get the biggest needle/angiocath you have
2. stab it into the trachea
3. hook up a 3cc syringe to the needle/angiocath and pull the plunger out
4. take a circuit connector from the top of a 6.5 ETT and snap it into the 3cc syringe
5. now hook up a bag/circuit and squeeze in the O2's
6. tell everyone this is the "MacGyver" airway

 

[pillowhead]

emergency surgical airway. what choice do you have at this point? if you've paralyzed the patient and can't ventilate through face mask or LMA and don't have any difficult airway supplies right there, you've found yourself at the end of the difficult airway algorithm.

i supposed you could leave the goosed tube in and try to intubate around it. it's a horrible place to find yourself. ESPECIALLY if you're not in the OR.

 

[proman]

By this point, ENT had arrived with their own cart (less than 5 min from when we called). They intubated using a Hollinger/Eschmann stylet. A surgical airway (or needle) would have been a nightmare given her habitus. No neuro deficits as best we can determine. She had her surgery the next day, possibly complicated by a post-op MI (not sure since I haven't been to the hospital since this happened).

I didn't do the physical exam, but I don't know if I would have wanted to delay until the equipment was in the room. We should have left a functioning LMA in place and waited (though the patient never had spontaneous resps). We almost never wake people up because the LMA-fiberoptic-Aintree combo has such a high success rate. I think the LMAs failed after the DL because the epiglottis was obstructing the glottic opening. There are reports of this.

Emergency cases frequently cause people to rush crucial steps, which is why I think we were unprepared.

 

[rsgillmd]

Why not take a quick look after you lost the ability to vent but before you gave paralytics. If looks ok, give the sux and tube. If not, then put in your LMA, which apparently worked the first time.

I never understood this approach of looking then paralyzing and looking again to pass the tube. If you are going to look without paralyzing and see the cords, why not just pass the tube? That's what I do for most of my floor intubations -- sedate and intubate. Not all of them even require sedation. If I don't see and I think muscle relaxation will help me, or if the patient is breathing too fast to slip the tube between respirations, then I'll paralyze. I've rarely needed the paralytic.

Sorry to divert from the discussion, but I just had to ask the question.

BTW to the original poster, as one of the other posters pointed out, this should not have been an unanticipated difficult airway. His attending should already have been suspicious just based on the information provided.

 

[ecCA1]

"I never understood this approach of looking then paralyzing and looking again to pass the tube. If you are going to look without paralyzing and see the cords, why not just pass the tube? That's what I do for most of my floor intubations -- sedate and intubate."

Exactly. By giving paralytics, you burned your bridge.

Shoulda just seen the cords and rammed that bitch home.