Your opinion difficult airway

[DrBrown]

40 y/o male alcoholic with bad upper GI bleed. HR 115, BP 101/70. Crit dropped from 35 to 28.. Lethargic d/t sedation given during unsuccessful Endoscopy. H/O difficult airway MP-4 requiring fiberoptic intubation. Big, short bull neck. Too sleepy to open mouth well for airway exam. Starts vomiting and coughing up blood upon arrival to preop area. Any ideas on how you would handle this? I will tell you what we did....

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[coprolalia]

GlideScope in one hand, suction in the other. Alcoholic? No additional sedation/induction agent. Use Brutane and/or paralytic (succinylcholine). Don't mask him, but make him breathe 100% O2 for a little while before you smack him down with the sux.

Been in this exact same scenario. Worked like a charm.

-copro

 

[zippy2u]

Ah Slick, before we get our panties all in a wad, how 'bout tellin' us what surgery/procedure this guy is goin' for. For all we know, the transport girl could have freaked with all the blood and ditched him in the preop area "because that is where a bunch of doctors congregate." Crazier things have happened in an academic hospital... Regards, ----Zippy

 

[DrBrown]

he was going for surgical repair of this GI bleed

 

[militarymd]

he was going for surgical repair of this GI bleed

most of these die anyways.

 

[fastosprintini]

well, it depends , is it an outright emergency that cannot wait? if not , i'd wake up the guy a bit, topicalize the airway, have really good iv access, transfuse, call for ent standby etc..
now, if things are more urgent i'd go with copro's idea, suction that actually sucks, people to hold the guy down while i sneak the bullardscope (my favorite) in. as soon as i see that i can intubate him i'll do so, with or without sux.
of course, should a crna with dnp happen to be around i'd hand over the case to him/her and go back to bed...;-)

 

[Planktonmd]

I assume the GI bleed is not from esophageal varices since he is going for surgical repair.
Have someone who can do a tracheostomy standing by.
Put in an NG tube and empty the stomach as much as you can, give Motoclopramide, give Glycopyrrolate, use an atomizer with 4% Lido for topical anesthesia and be generous with that, do an awake fiberoptic or awake glidescope but do not give any muscle relaxant (the patient is a documented difficult intubation and there is no reason he is going to be easier today).
If things are more urgent and he is crashing let them start working on the tracheostomy and do one attempt with whatever you feel you are best at but don't make an urgent situation a dire emergency by giving a muscle relaxant and loosing the airway.

 

[DrBrown]

Thanks for the ideas. We did topicalize with cetacane and nebulized lidocaine. Too unstable to wait. 2 mg versed and 100 mg ketamine and awake glidescope. We felt like the blood we obscure the view with the fiberoptic. Surgery was in the room, should we need a trach.

 

[Planktonmd]

Thanks for the ideas. We did topicalize with cetacane and nebulized lidocaine. Too unstable to wait. 2 mg versed and 100 mg ketamine and awake glidescope. We felt like the blood we obscure the view with the fiberoptic. Surgery was in the room, should we need a trach.

100 mg ketamine makes the intubation anything but "awake".
Good plan though.

 

[DrBrown]

In most cases I would agree. He was still spontaneous throughout and even after the ketamine was titrated in he still was reaching for the tube. I really just wanted to see how many would try the fiberoptic with the patients pharynx full of blood and what would you do if there was no glidescope. Thanks for the replys

 

[Planktonmd]

In most cases I would agree. He was still spontaneous throughout and even after the ketamine was titrated in he still was reaching for the tube. I really just wanted to see how many would try the fiberoptic with the patients pharynx full of blood and what would you do if there was no glidescope. Thanks for the replys

I would still try the fiberoptic because the notion of difficult fiberoptic when there is blood in the pharynx is way over rated.

 

[bostonblaz]

with spontaneous breathing sometimes a fo is not soooo bad as every time he breathes bubbles are made and you can aim for them. that being said in a case like this i like precedex, midaz, propofol prn, and a intubating lma, he can bite that metal piece all he wants and he wont bite through it and it still leaves me the ability to vent him and i can throw a scope down it.

 

[DrBrown]

We thought about precedx but did not use it assuming he was hypovolemic due to the bleed itself.

 

[Jeff05]

2 issues: this is for the ORAL boards



1. difficult airway
2. aspiration.

difficult airway always wins. this guy should NOT go to sleep without a tube in the trachea. period. do whatever it takes to get it in there ON the boards...


here's the difficulty, if he's bleeding it could be a mallory weiss...doing a transtracheal block and having this guy cough violently would kill him as well...but, this would be too much for the ABA. DIFFICULT AIRWAY = AWAKE INTUBATION.

i would give this guy glyco, ketamine - titrate slowly to maintain spont respiration... and take an awake look with a glidescope/fiberoptic.