Clinical Case 069: Can’t Intubate, can ventilate …. for now
I always thought that Beaker would be the toughest Muppet to intubate. Sure he’s skinny, but a non-existent thyro-mental gap and that big nose will impede cord visualisation…any other thoughts?
Todays case is one of those unique country-doctor scenarios. Sure it could happen anywhere, but working in a small town has a few special and unique moments which really make one think!
Our patient is a 47 yo. woman who you know well – actually she is your anaesthetic nurse, the person who hands you the tube, checks your machine and brings you coffee during those long, boring cases!
The basic history – usually a well woman who suffers from seasonal allergic rhinitis. Has been getting a bit of sinus symptoms recently and took the day off work yesterday with a “bad migraine”.
She was brought to the ED by her son who found her crying in pain with a headache and thought she seemed a bit confused. About 20 minutes after arriving in the ED she drops her GCS from 15 down to 8. Her other vitals are normal and she doesn’t have any localising neuro signs. This is not a stranger, this is a lady you know – them whole team is really tense.
At the moment you are happy that she is maintaining her airway without support, but you are 250 km from the closest CT machine and 1800 km from the closest ICU or neurosurgeon etc. She has to go “south” fast. The RFDS are alerted and a plane is tasked.
She is loaded with IVABs and the decision is made to intubate and ventilate for the likely 6 – 8 hour transfer. The most senior GP anaesthetist is called and he prepares for the intubation. She has never had a GA before according to her chart.
This all happens quickly and 10 minutes later she gets a pretty standard, old school RSI mix with propofol, sux and fentanyl. Direct laryngoscopy = invisible epiglottis, BURP, cricoid / laryngeal manipulation do not help. Ah, bugger! A second look with a quick reposition = still no view, a blind bougie pass goes oesophageal and now there is a little mucosal bleeding happening.
The sats start to decline, so an LMA is placed and she is pretty easy to ventilate / oxygenate. Time for a quick head scratch – more heads and hands are called in from home to assist. The Sux wears off and she starts to fight the LMA.
OK, what do you do? The hospital doesn’t have a fibre-optic scope or video laryngoscope of any type.
- What drugs are you going to give? Sedation, further paralytics?
- Which airway manoeuvres will you try next?
- Is it worth further attempts from above?
We decided to try a blind intubating LMA next. So the LMA was swapped for a Fast-trach device and it was noted that it was more difficult to move air, there was a bit of stridor, yet she did not desaturate.
The ETT was passed along the LMA nad despite all the recommended tricks we could not get it to go into the trachea. Further pushing and prodding had caused a bit more airway injury. The ventilation was sounding noisier by the minute.
So here we are – in this hospital at the time we had arrived at the bottom of the algorithm. Intubation from above was not working. Ventilation was not easy now, and we had a long plane flight ahead of us. It was not a true CICO, but could go that way if we made matters worse by ongoing attempts.
As luck would have it one of the GP-Anaesthetists had just returned from a week of “refresher” training in the big smoke, and had taken the wet-lab training on Surgical airways with Dr Andrew Heard.
So we opted to do a controlled, simple scalpel-bougie-assisted cricothyroid airway and inserted a 6.0 cuffed paeds tube. This took about a minute to complete and gave us a nice secure airway. There were audible sighs form all of us – it was a good call and our mate was safe for now.
The main thing we had to avoid in this scenario was any period of hypoxia or hypotension as we had no idea as to what was going on in her brain and desperately wanted to avoid a secondary injury.
Now – back to the big question. What is going on – what is the diagnosis? I think I’ll let you guess. Will update soon.
OK, Im reading this without looking at what happened, and I’m, learning a lot from the case scenario.
No fiberoptics, can’t see anything, but can ventilate with an LMA.
How about I give you a few ways to go here?
1. Re-sedate patient with additional propofol to maintain her tolerance of LMA, but omit the Succinylcholine.
2. Topical lidocaine through the LMA (8 ml 4% dilute in 20 ml total volume will be an awesome nerve block for the purpose of trans-LMA intubation). 30-50 mg aliquots [Ed: of Propofol] are a safe way to go.
3. Tracheal tube 6.0 cuffed preparation for blind intubation through LMA: Remove 15 mm connector, place tip of tracheal tube into the portion of tube normally occupied by connector. Wait for the plastic to get some “memory”. Place patient’s head and neck in the maximal amount of extension that her body will allow.
4. Blind LMA intubation is much like blind nasal intubation–you advance the ETT, listen, and re-position left/right twist slightly as you listen to breath sounds. Often, it is required to withdraw the LMA slightly to flatten the “angle of attack” of the tracheal tube to the glottis.
5. As the tracheal tube approaches larynx, a slight left or right turn may be necessary to clear the vocal cords. Watch the Thyroid cartilage itself to see where the tracheal tube bumps the laryngeal cartilage, and adjust appropriately.
6. Gentle cricoid pressure may help.
7. The next technique—all of the above, but put a retrograde wire through the cricothyroid membrane up through the LMA (I’ve never done it, but I will try it next time I get to Rich Levitan’s cadaver lab). Then retrograde intubate through the LMA.
[Now – back to the big question. What is going on – what is the diagnosis? I think I’ll let you guess. Will update soon.] My answer—-Are you hinting at a subarachnoid hemorrhage? Why else would you go to the extent of securing her airway?
Thanks Jim. Wish you were there!
Great tips. At which point would you stop trying non-surgical approaches – if she became hard to ventilate? If SpO2 dropped? How do you decide when it is not a true CICO scenario?
But, no – it wasn’t a SAH. Could have been… but it was something else….. any takers?
it was cavernous sinus thrombosis, n’est ce pas?