Clinical Case 143: a Perfect Airway Storm

This episode I reflect upon a really tough airway case.

I have asked a number of airway gurus from the FOAMed community to comment on the logistics and plan to manage this case.  Thanks to Tim Leeuwenburg, Rich Levitan, Roger Harris and Dr Richard Lewis of their contributions.

The patient

50 year old woman with a complicated medical history.

  • life long smoker & drinker
  • had large goitre resected 10 years ago with large anterior neck dissection
  • diagnosed with SCC of base tongue 3 years ago
  • large resection / reconstruction including mandibular graft
  • Radiation therapy to the anterior neck with lots of fixed scarring to neck.
  • Previous intubation (prior to XRT) was grade 3 and required a bougie for anterior larynx / hyper-angulated airway
  • Now quite cachexic but has no palliative intention

The situation

Presents to a remote ED (2000km from the next specialist ENT / Anaesthesia /ICU service.

Developed oral bleeding from fungating lesion on the posterior lateral tongue.

Has been contiuously bleeding for an hour, tachy 130, normal BP, has a bag of blood in hand ~ 1000 ml.

Vomited a few times – altered blood / coffee grounds

On examination there is a fungating lesion that we cannot see past ie. You can see the front of the lesion covered in an oozing clot but it extends past the possible field of view around the back of the tongue.

The jaw is microagnathic / graft with a lot of scar tissue.

The anterior larynx is best described as a block of fixed tissue with woody texture. It is impossible to clinically feel the cricothyroid / thyroid cartilage or membrane reliably


Bloods – Hb is now 79 (was 110 on recent check). Platelets 150

Normal renal function

Coags are normal

LFTs – raised GGT and ALT – chronic

No imaging / CT available

The problem

This patient is exsanguinating – we need to control the bleeding. IV TXA, topical adrenaline and TXA gauze help control external bleeding, but she still seems to be gagging and swallowing a lot of blood, vomiting intermittently coffee grounds.

We have blood to transfuse ready to go…

To do this properly we need to control the airway / get a tube in place.

How should we do this…?

AFOI – is going to be tricky

RSI – also requires we accept the risk of going to surgical airway…. Which may be tricky

Needs to go to the tertiary hospital on a plane… this is unlikely to occur without a secured airway.

OK doc – the surgeon is scrubbed and ready to get in there… what the plan?

What do you do if AFOI proves to be impossible / failed?

Have a listen to hear how it played out and what the airway experts think!



  1. From reader , Dr H

    Liked the airway case. My worst airway was a 54y man who walked past me in busy ed (single doctor 6 beds, 5 full, waiting room full of people waiting to be seen). Looked well, but had stridor. I went to see him while the nurse was triaging him, he was talking and joking, just wanted AB for a cough that was getting worse. Did urgent CXR- Got called to Xray to see the result- huge chest mass. We have a CT so did that- only lying him flat at the last minute for the CT. CT showed a huge mass in the upper chest,. Patient got very SOB lying flat and more stridor, so sat back up, in ED started having severe trouble breathing. As stridor -- > neb adrenaline, non stop. CT showed his trachea was narrowed to 4 mm , down behind the sternum. So surgical airway wasnt going to work.!. Long story short- I took him by road to meet retreval in a roadside carpark. Made it to tertiary hospital and they did awake intubation. Mass was a goitre, that had bleed into a cyst , probably from his coughing. V Scary.

    Thank you for sharing

    • Adnane Lahlou says:

      Gave me the chills there. I belive trying to secure the airway with a small caliber tube wouldn’t have worked either.

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