Worst Airway I've Seen in a While

[Noyac]

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I show up in the middle of the night to do a D&C when I find no OR staff except for the PACU RN. she says they just went to the ICU with a trach set. Well I'm curious so I go to see what is going on. When I walk into the ICU everyone says "ROOM 17, fast". 😱

I see a bunch of docs, rn's and respiratory terrorists scrambling around with big eyes. THis guy (the pt) has a head the size of a basketball, literally. No neck, arms contracted completely up around were his neck should be, skinny little contracted legs and a chest that looks like its been squeezed at both sides until the sternum protrudes up above his chin. He is obviously wheelchair bound. Sats are low 70's, face blue. BP 85/50 HR 110's. Board on the wall says spinal muscular atrophy 😕. Resp terrorist is bagging about 10 times a minute with a huge leak completely ineffectively. ER doc holding BOOP, BOMP whatever. Nasal trumpet spitting out frank blood and ICU doc standing there with a bloody fiber optic scope in his hands. Surgeon looks at me "Noyac (he used my real name), would you put a tube in this guy". I said sure, no problem. Swing around to the top of the bed and take over masking. I get the sats to 90's and go to take a look. **** I can't open his mouth enough to get the blade more than 2-3 inches in. Ok, I ask what he has been given so far. Er doc says, I gave him succ's 😱. Oh well I guess you got away with that one. Oh and his jaw has a boney contracture, he tells me. Well since I can mask him somewhat and we got a trach set and surgeon ready, I paralyze him with 10mg vecuronium (he wasn't making any respiratory efforts at all so if can't hardly get worse). We also notice that he has a previous trach scar so great we got a site to start with. This trach was the hardest I have ever seen. No neck, previous scar,chin and chest basically touching each other. Blood spitting everywhere from the mouth and nose and I got to mask this guy for at least 30 minutes. About 15 minutes into it he starts to . The two surgeons still aren't sure what they are looking at and the whole site is bleeding like crazy without any bovie to carterize. They are trying to tie off the bleeders while I keep ventilating through the barf and suctioning. Sats remain 92% throughout the procedure and we finally get into the trachea, all is well.

Now don't that sound fun. How many specialties get to do kool stuff like that?

 

[coprolalia]

Shoulda had a Glidescope. 'Nuff said.

-copro

 

[numbmd]

But he couldn't fit a blade 'cause the mouth wouldn't open.
Glide is too big.
Now maybe a bullard.....

 

[Planktonmd]

This whole disaster could have been avoided had they recognized a difficult airway and called the anesthesiologist initially.
Simple fiberoptic intubation.

 

[Gern Blansten]

This whole disaster could have been avoided had they recognized a difficult airway and called the anesthesiologist initially.
Simple fiberoptic intubation.

Agree. It should have been done in a controlled fashion instead of when the patient was in trouble. If it was already F.U.B.A.R. when you got there, not much you can do to get it back to a good situation. Did someone along the way notice it may be difficult or did they just press ahead with induction drugs?

 

[Noyac]

Shoulda had a Glidescope. 'Nuff said.

-copro

We have one, but the mouth wouldn't open enough. Plus even if the mouth did open enough the cord coming out of the glidescope handle would have been in the way with this guys chest the way it was. It is doable but that 3 inch cord connection is a problem from time to time.

 

[Noyac]

This whole disaster could have been avoided had they recognized a difficult airway and called the anesthesiologist initially.
Simple fiberoptic intubation.

True, but in their defense. I think this guy rolled into the ER in bad shape and they moved straight to the ICU and he was arresting (resp) in the process so time was very limited. I was not in house and they needed immediate measures. But they are very aware of the benefits of calling an anesthesiologist asap. 👍

 

[Noyac]

Agree. It should have been done in a controlled fashion instead of when the patient was in trouble. If it was already F.U.B.A.R. when you got there, not much you can do to get it back to a good situation. Did someone along the way notice it may be difficult or did they just press ahead with induction drugs?

As noted above, they were sort of forced into this scenario. This guy was FUBAR from the start, on arrival.

 

[treasurefull2]

As noted above, they were sort of forced into this scenario. This guy was FUBAR from the start, on arrival.

FUBAR?

 

[coprolalia]

FUBAR?

It's German.

-copro

 

[coprolalia]

We have one, but the mouth wouldn't open enough. Plus even if the mouth did open enough the cord coming out of the glidescope handle would have been in the way with this guys chest the way it was. It is doable but that 3 inch cord connection is a problem from time to time.

Well, if the mouth wouldn't open wide enough then that's a problem. And, the Bullard definitely is not going to fit in if the Glide isn't going to fit in.

-copro

 

[Saluda]

It's German.

-copro

 

[Gern Blansten]

FUBAR?

F'ed up beyond all recognition

 

[treasurefull2]

who came up with that?

 

[ear-ache]

who came up with that?

Don't know... but it was used in "Tango and Cash". Great formulaic 80's film.

 

[coprolalia]

Yeah, wasn't sure if anyone else would catch my "Saving Private Ryan" reference.

-copro

 

[UTSouthwestern]

Had this situation before. Retrograde intubation special. Even if you miss, you haven't destroyed any chance at the trach.

 

[jwk]

This whole disaster could have been avoided had they recognized a difficult airway and called the anesthesiologist initially.
Simple fiberoptic intubation.

Airway full of blood and simple fiberoptic intubation don't seem to go together. 😉

And fubar is way older than the 80's.

 

[leaverus]

For my edification: fiberoptic nasal intubation? Would anyone consider that, or is that just not an option for an ICU patient who will likely have a prolonged interfacing with the ventilator? Even if you had been able to get an oral ETT in this guy, he probably would have bought himself a trach down the road, i imagine.

 

[Noyac]

For my edification: fiberoptic nasal intubation? Would anyone consider that, or is that just not an option for an ICU patient who will likely have a prolonged interfacing with the ventilator? Even if you had been able to get an oral ETT in this guy, he probably would have bought himself a trach down the road, i imagine.

The FO nasal intub would have been fine b/4 the bleeding assuming you could do it fast enough. I was told that this guy was a resp arrest, I wasn't there at the start so I can't verify this. I don't regard a nasal ETT contraindicated in the ICU but there are definitely better choices.

He was trach'd in the past for some reason and he was very likely going to be trach'd again even if someone was able to orally intubate this guy. The problem was that this guy was not going to be an easy trach either. Luckily I could mask him. Don't forget that effectively masking someone is the most important skill we have in airway management. If I couldn't have masked this guy (like the ER doc and the RT) we wouldn't have had him trach'd in time. I'm telling you, his neck or lack of one was bad and those quick cric sets are not as good as some people may think they are.

By the way, he died the next day of sepsis. His first blood culture, taken when he arrived in the ER grew out gram - rods.

 

[jwk]

Luckily I could mask him. Don't forget that effectively masking someone is the most important skill we have in airway management. If I couldn't have masked this guy (like the ER doc and the RT) we wouldn't have had him trach'd in time. I'm telling you, his neck or lack of one was bad and those quick cric sets are not as good as some people may think they are.

Bingo - that's the take-home point. Very few people outside of anesthesia can adequately mask ventilate a patient. Plenty of ER docs and paramedics and RT's think they can, but they really can't.

I wonder how many of y'all still do cases with a mask (or ever did for that matter), or is it just something you use between induction and placing an LMA or ETT?

 

[numbmd]

And, the Bullard definitely is not going to fit in if the Glide isn't going to fit in.

-copro

Try taking the stylet off first. all you need is like 11mm of mouth opening........

All right, let the jokes come.

 

[Planktonmd]

Airway full of blood and simple fiberoptic intubation don't seem to go together. 😉

The airway becomes full of blood after you traumatize it not before!
When you see limited mouth opening in someone with a tracheostomy scar and a head like a basketball you should strongly consider awake fiberoptic intubation before you make the airway FUBAR.😉

 

[numbmd]

noyac, consider an LMA? not necessarily an intubating one. just a regular one?

Doesn't protect the airway, but either does masking. The ER dudes might have put a lot of air into the stomach when they tried to mask, it might have aggravated/accelerated his vomiting.

Just another thought.

 

[Noyac]

noyac, consider an LMA? not necessarily an intubating one. just a regular one?

Doesn't protect the airway, but either does masking. The ER dudes might have put a lot of air into the stomach when they tried to mask, it might have aggravated/accelerated his vomiting.

Just another thought.

Good question Numbnuts (had to say it, but seriously joking. Had a few cocktails). I sent the OR RN for an intubating LMA since the classic one was already present in the ICU. This was b/4 I paralyzed the guy. I really thought that once I paralyzed him everything would be fine. I thought I would be able to intubate him without any problem and I would have if I could have just opened his damn mouth. But I sent them anyway for the fasttrack LMA. That device has not failed me yet. Unfortunately, once I paralyzed him I still could not have managed to slip an LMA of any sort through his teeth.

I'm sure it is obvious after reading above that I have had a few Spruce Gooses. Local beer approx'ly 9% etoh made with fresh clippings of spruce trees in the spring. My personal favorite during the holidaze.

 

[Noyac]

I wonder how many of y'all still do cases with a mask (or ever did for that matter), or is it just something you use between induction and placing an LMA or ETT?

I had a few attendings that understood this concept. I will never forget when one of them said to me in the middle of the night "you are going to mask this case". It was left over from the day when a surgeon went well over his scheduled time.

Those of you in residency that have not masked a whole case need to do it. Before you know it you will be able to mask the pt, chart your records, give meds, move the table, flirt with the hot nurse, order lunch, and whatever it is you do behind the curtain. Just do it b/4 its your arse on the line.

 

[Apollyon]

Bingo - that's the take-home point. Very few people outside of anesthesia can adequately mask ventilate a patient. Plenty of ER docs and paramedics and RT's think they can, but they really can't.

In New York state, in all my levels of EMS (EMT, EMT-Intermediate, and Paramedic), the practical exam had BVM on it (because the BLS skills had to be passed at every level), and they had the mannequins that had the volume measure on it - you had to light up the green light to be right (if a light didn't light at all, it wasn't enough, and, if the red light went on, the TV was too much). I can tell you that that, seriously, helped out with knowing "how much, how hard". I don't know what happens in other states.

 

[leaverus]

Mannequins would be good for practicing rate and TV, but that's it. They wouldn't help at all for learning to maintain patency of an obstructing airway -that only comes from real-life experiences. What good is it if you can push a perfect 700cc of 100% O2 at a steady 12breaths/min if it's all going into the stomach? That's what Noyac meant.

 

[gas87]

Does anyone get a chance to learn these in residency anymore?
Can anyone think of a non-emergent situation where it would be appropriate (i.e. not causing more harm to the patient) for residents to learn these?

Maybe it would have been hard in this case where it was hard to find the neck anatomy, but it requires a lot less equipment (anyone else ever had a hard time finding the glidescope/fiberoptic scope in an emergency)? And, it would be good to feel comfortable doing this for situations when the power goes out (anyone remember 2003)?

 

[Noyac]

Does anyone get a chance to learn these in residency anymore?
Can anyone think of a non-emergent situation where it would be appropriate (i.e. not causing more harm to the patient) for residents to learn these?

Maybe it would have been hard in this case where it was hard to find the neck anatomy, but it requires a lot less equipment (anyone else ever had a hard time finding the glidescope/fiberoptic scope in an emergency)? And, it would be good to feel comfortable doing this for situations when the power goes out (anyone remember 2003)?

Your right, the retrograde is a good skill to have. And it is quite possible that this technique would have worked on this pt. I considered it but it was obvious that he was going to need a trach anyway.

 

[Noyac]

Mannequins would be good for practicing rate and TV, but that's it. They wouldn't help at all for learning to maintain patency of an obstructing airway -that only comes from real-life experiences. What good is it if you can push a perfect 700cc of 100% O2 at a steady 12breaths/min if it's all going into the stomach? That's what Noyac meant.

I think what Apollyon was getting at was that BMV was stressed in the training which is a good thing. I'm sure s/he understands that there is no substitute for the real thing. Thats how I read his/her post, anyway.

 

[gasnewby]

Does anyone get a chance to learn these in residency anymore?

i've only seen ER residents attempt this. they usually call us for a cric and on arrival the pt has a wire or two sticking out of their neck. not necessarily in the trachea. and is a bloody mess.

 

[rsgillmd]

We do >95% of our D&C's as GA by mask, but those are usually quick.

The longest I've had to mask for was about 45 minutes. I forget all the details, but it was one of those cysto cases. Couldn't get even an LMA 3 into this lady, and neither could my attending. We could have intubated her I suppose (as I said, I don't remember all the details -- I was a CA-1), but decided to do the case as a mask case.

She was easier to ventilate with an oral airway, so I used it and used a headstrap to make things a little easier for myself. Gave meds via a stopcock, moved the machine close to me, and got myself a stool. No reason to struggle if you don't have to.

I worked EMS from 1995-2005, both paid and volunteer. I thought I had decent mask ventilation skills. I will be the first to admit that they improved once I started my anesthesiology residency.

Once when I was a CA-1, I went down with my senior resident (CA-3) to the ER to help with an intubation. Airway already a challenge. I saw the way the ED attending was ineffectively mask ventilating the patient. Not knowing he was an attending (I thought he was an RT), I said "Here, let me take over" and verbalized what I was doing. In the meantime my senior resident got ready to attempt a laryngoscopy. As the sats came up I said, "See, how that's made a difference. Now we've got a more controlled situation." After I said that was the point I saw his nametag. Felt bad for the choice of words, and needless to say, quite embarrassed. My senior resident was able to get the intubation using a bougie. Anyway, just thought I'd share that story to give you guys a laugh at my expense.

 

[coprolalia]

I've done one awake, retrograde, wire intubation in the PACU before going to the OR. Probably could've done it some other way, but this was for practice.

The patient? 700 lbs. All tongue. Mallampati 5. Cor pulmonale. Prior trach. We did it with one of our former Navy attendings who was somewhat of a specialist in airway management. It was me, the attending, and one other resident. Done awake.

First, 4% nebulized lidocaine. Next, transcutaneous laryngeal block. Then, small skin wheal of 1% lidocaine over the cricothyroid membrane. 16g Gelco angiocath through the cricothyroid membrane. More 4% lidocaine into the angiocath directed caudad. Aimed the Gelco cephalad. Passed the J-wire cephalad while placing a tongue depressor in the patient's mouth with a headlamp on (attending did this). Grabbed J-wire with a small Magill's forceps. Gently directed wire outwards through the mouth. Placed 7.5 ETT over wire. Railroaded tube down over the wire until you could feel the crunch going through the cords and then resistance against the internal portion of the trachea (I did this). Pulled wire through the tube from the "mouth" portion of the tube. Inflated cuff. Gave two breaths with CO2 indicator. Anesthetized the patient with Etomidate. Fiberoptic scope down the tube to cofirm the position. The whole time the patient was sitting up at about a 60-degree angle. Must've had an audience of about 12 people, including several PACU nurses.

It was really cool to do this, but impractical. Done solely for teaching/learning purposes. I think we could've easily gotten it with the Glidescope. I love that thing. Now, recent Glidescope story...

Called to ED for "can't intubate". On my way down, I grab the Glidescope from the workroom in the OR. Arrive, patient is a nice shade of purple and snot is coming out of the mouth and the nose. All you see is the guys protuberant tongue hanging out of his mouth. They've already given 1mg atropine. Bloody Mac 3 and Miller 2 laying next to the patient. Snotty LMA also laying next to the patient. SpO2 is in the 40's and the heart rate is about 110. The guy probably weighs 350lbs. Micrognathic. His neck is about as thick as his head. The ED attending has busted the guy's lip and blood is all over his mouth and face. I plug the Glidescope in and turn it on. Screen pops on right away. I stick the large disposable blade down after a quick suction. Blood and mucus in the hypopharynx. Yankauer goes down and I suck maybe 20-30 cc's of blood and mucus out of the back of the guy's throat. Have to finagle a little bit, but see the cords. 8.0 ETT bent like a hockey stick. I'm able to place it against the cords, but won't go through. I say, "Pull the stylet out." Someone does this. The tube passes right through the cords under direct visualization. CO2 color change. Bag him a few times. Push rocuronium and etomidate. Pinks up. Sats come up. The ED resident tells me I "cheated". I laugh.

Friggin' cool device, man.

-copro

 

[bluewater]

without mouth opening, maybe blind nasal?

 

[norwood]

Does anyone get a chance to learn these in residency anymore?

In the sense of doing one on a mannequin, yes. Never seen one performed on an actual patient, though, and haven't spoken with any other residents at my program who have done one.

 

[urge]

Does anyone get a chance to learn these in residency anymore?

I tried during residency for a difficult airway. My attending wanted to modify it by inserting a fiberoptic scope over the wire to visuliaze where we were going. Don't ask me why or how he came up with that idea. We used some sort of really long plastic "wire" so that it would be long enough for the scope. BIG MISTAKE!!! The scope wouldn't easily slide over the wire and eventually got stuck. Leaving us tugging the scope and wire in and out in a half awake patient jumping all over the place. Eventually we had to cut the wire and ended doing a plain old fiberoptic intubation. It was a huge learning point: you don't need to see where the stuff you are sticking in is going. Every human being born is evidence of this.

 

[coprolalia]

In the sense of doing one on a mannequin, yes. Never seen one performed on an actual patient, though, and haven't spoken with any other residents at my program who have done one.

(1) Find a suitable/appropriate patient.
(2) Find a willing attending.
(3) Ask if you can do it.

A lot of time all you have to do is the above, and you'll be able to get your chance to do it.

-copro

 

[Jeff05]

called to ed to intubate obese, bearded pt with neck stuck in flexion. before i get there the ed attending pushed prop and succ without preox. he just wanted to "take a look." can't put blade in mouth or ventilate. sats in 60s. i take over, glidescope, tubed in 5 seconds. this is a classic situation.

tons of stories of icu fellows, ed chiefs/attendings, peds residents not only traumatizing airways, but endangering patients by trying to "take a look," pushing meds and ignoring basic tenets of airway management (preox, etc)

in my opinion, none anesthesiologists should only intubate when it is absolutely indicated to save a life (almost never) and when anes is not available. otherwise, bag it.

my opinion, learning how to mask/bag ventilate a patient/insert oral airway should be the primary focus of airway training for non-anesthesiologists.

 

[Planktonmd]

called to ed to intubate obese, bearded pt with neck stuck in flexion. before i get there the ed attending pushed prop and succ without preox. he just wanted to "take a look." can't put blade in mouth or ventilate. sats in 60s. i take over, glidescope, tubed in 5 seconds. this is a classic situation.

tons of stories of icu fellows, ed chiefs/attendings, peds residents not only traumatizing airways, but endangering patients by trying to "take a look," pushing meds and ignoring basic tenets of airway management (preox, etc)

in my opinion, none anesthesiologists should only intubate when it is absolutely indicated to save a life (almost never) and when anes is not available. otherwise, bag it.

my opinion, learning how to mask/bag ventilate a patient/insert oral airway should be the primary focus of airway training for non-anesthesiologists.

You know what the scariest part is?
Not knowing what you don't know!
Mask ventilation and airway management by non anesthesiologists is under this category: everyone does it but most of them don't know what they don't know.
Not knowing what you don't know is good for the ego and for self esteem but not too good for the victims.

 

[Noyac]

You know what the scariest part is?
Not knowing what you don't know!
Mask ventilation and airway management by non anesthesiologists is under this category: everyone does it but most of them don't know what they don't know.
Not knowing what you don't know is good for the ego and for self esteem but not too good for the victims.

There inlies the problem with our midlevel providers.

 

[Gern Blansten]

without mouth opening, maybe blind nasal?

In my experience, this works well if you have a spontaneously breathing patient. This particular case sounds like that was not the case. Blind nasals are very nice when they work well, but can be a bloody mess if you stir up bleeding. Not a good idea if they are planning on heparinizing the patient or using thrombolytics (ie PE or acute MI). That being said, I like this technique and have had a lot of success with it.

 

[Arch Guillotti]

In my experience, this works well if you have a spontaneously breathing patient. This particular case sounds like that was not the case. Blind nasals are very nice when they work well, but can be a bloody mess if you stir up bleeding. Not a good idea if they are planning on heparinizing the patient or using thrombolytics (ie PE or acute MI). That being said, I like this technique and have had a lot of success with it.

I think that blind nasal is an underused means of securing the airway. I have only seen/heard of a couple of people doing them but in each case the airway was secured nicely. Usually in a case up on the unit/floor where someone from anesthesia was by themselves facing a pt. in extremis with a not so good looking airway.

 

[Arch Guillotti]

called to ed to intubate obese, bearded pt with neck stuck in flexion. before i get there the ed attending pushed prop and succ without preox. he just wanted to "take a look." can't put blade in mouth or ventilate. sats in 60s. i take over, glidescope, tubed in 5 seconds. this is a classic situation.

So do you tote the glidescope down there with you regularly, or is it easily accessible down there?

 

[Gern Blansten]

I think that blind nasal is an underused means of securing the airway. I have only seen/heard of a couple of people doing them but in each case the airway was secured nicely. Usually in a case up on the unit/floor where someone from anesthesia was by themselves facing a pt. in extremis with a not so good looking airway.

You have described the exact patient that I prefer using this technique on. You rarely lose anything by trying it(exception-massive nosebleed) and most of the time it works.

 

[UTSouthwestern]

Nobody use the lightwand any more?

 

[militarymd]

Nobody use the lightwand any more?

I do...it's my first go to piece of equipment.

 

[coprolalia]

So do you tote the glidescope down there with you regularly, or is it easily accessible down there?

Personally, whenever I'm called to an airway emergency, I grab the thing and take it with me if I have time to go get it. In the ED when I get called (which is rare), I now try to always take it with me. I figure if those guys can't get it, someone's probably in deep doo-doo.

-copro

 

[Arch Guillotti]

Nobody use the lightwand any more?

I still try to practice these whenever I get the chance in the OR. I don't use them much on floor intubations tough, usually just DL. I do think that they can be an invaluable tool on the floor if it is used properly. I know of a couple of situations in which it was literally a lifesaver. I don't think anybody else really knows what it is so that makes it all the more cooler when we put it in. I especially like the oohs and aahs when you have the lights cut out and then the trachea mysteriously lights up and wham the pt. is tubed.

I remember a case early in my CA-1 year when I was on an airway call with the CA-3. The pt. was an old guy going into respiratory failure and in the process of having an acute MI. The confounder was that he had a known cspine injury and was in traction with the weights hanging off the head of the bed. Fiberoptic was atttempted but the airway was a mess of secretions and such and thus was pretty useless. The CA-3 slapped in a lightwand with little if any neck movement in short order. Pretty good stuff.