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? 

The next GP-anaesthetist to arrive also decided to have a look – I think this is one of the things we do – untrusting types! And, yes, she was still unintubatable on direct laryngoscopy, further suctioning and probing resulted in a bit more  mucosal oedema.

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.




  1. 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?

  2. 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?

  3. minh le cong says

    it was cavernous sinus thrombosis, n’est ce pas?

    • Desole
      Fermer mais aucun cigare.

      Minh is on the right track though

      • minh le cong says

        what kind of French is that?
        Then it was sagittal sinus thrombosis!

        • [Sorry, French via Google / Bing translate.]
          Exactamundo – central venous / sagittal vein thrombosis secondary to acute sinusitis.
          Good call Minh – of course it didn’t really help to know that a few days later. Sometimes not having a CT can allow greater clarity of thought and attention to the important things like A, B , C etc

          • minh le cong says

            lol..hahahahahaha, just realised what you were trying to say in French. CLOSE but not another cigar…dont let a computer do a human job in translation!

            any French speaking rural GP prehospital retrieval doctor worth their salt would have been able to diagnoses sagittal vein thrombosis without CT

            just kidding, mate. well done. good job. great case to highlight. Andy Heard would have been smiling on hearing the case!

  4. minh le cong says

    How could I forget you Casey for faculty on the #FOAMEd online airway training program!? Keeping it real since 0248hrs today!
    where was that flash new AP video laryngoscope you got from WA Health department??
    when bougie and Fastrach ILMA fail, the French prehospital study suggests immediate cricothyroidotomy. Ini their series the three techniques and DL managed over a thousand prehospital airways successfully.
    so well done, monsieur!
    let me be controversial as that is my nature.
    LMA is working so leave it in , either till RFDS arrive with their King Vision VL..or leave it in for whole 8 hr aeromedical retrieval. Was it a second gen LMA like Proseal or Supreme? If so, insert gastric drain, sedate further and paralyse and ventilate via LMA for whole retrieval. Its the RSA technique a la Braude And I have done this myself and advised other retrieval colleagues to do this on a bunch of occasions when intubation was difficult or failing. We have yet to have recorded a bad complication as a result of this LMA only strategy for ventilated retrievals. sure its going to happen but ini emergency airways with impending CICV/CICO scenarios, its a valid option. I think the better option is what yoj did, a surgical airway under LMA support.
    But why cut, if you can adequately anaesthetise and support the patient on a LMA? Considering this case the anaesthesia was given for airway support not ventilatory support. With LMA in partic a second gen one, you clear the airway, provide oxygenation and drain the stomach.

    even more controversially, how about waking your patient up once Scoline and propofol wear off and declare failed intubation but we can LMA ventilate..lets get her back to her own airway and reassess. No point rushing if there is no need to.

    GCS 8 is not an automatic mandatory indication to stick plastic down the trachea, partic if said tubing is difficult and may harm the patient during the attempt.
    I know of cases where collegues have gotten into the exact situation you describe, woken the patient patient and transported them in lateral position with OPG, with no complications.

    • All fair points
      I have learned a lot about airway management in the last 3 years [this case was in a former life].
      The main decision to press on with the surgical airway was the increasing difficulty with LMA ventilation – likely due to our many attempts / manipulations. Also we really had no idea as to what the pathology was – so a GCS of 8 initially could be 3 or worse in an hour depending on the pathology and its progression.

      Now maybe Qld flying docs are braver, but I don’t think my WA colleagues would fly that far without a definitive airway in place given the many unknowns of this case.

      Knowing how quick and easy the surgical airway was – I think it was a good call. My friend shows off her 2 cm scar to everyone – no harm done, so wher eis the downside. @emcrit has discussed this in his Cricon lecture I think

      • minh le cong says

        thanks mate. well done once again. agree indeed. but LMA anaesthesia and ventilation is an option even on retrieval. lets do a teaching google hangout session on it as part of the online airway training program!

        My favourite tips to achieve successful Fastrach ILMA intubation are :
        1. Jaw thrust by assistant at same time as attempted blind tube via Fastrach
        2. In and out maneuver to correct mask distortion
        3. Chandy maneuver with the handle of Fastrach, applying mask bowl closer to larynx.

        Fastrach ILMA and Air Q ILMA use is a neglected art of airway mgt… the blind tube.

  5. Difficult case – one of the challenges of small town country doctoring in Oz (and no doubt elsewhere) is that it is often colleagues, friends and occasionally family whom one has to manage through their critical illness.

    You KNOW i’m gonna wade in on this one, as it highlights my particular passions of both :

    (i) access to difficult airway equipment and

    (ii) fighting to bring same level of care from city to country.

    FWIW I would have done same…declared failed intubation, maintained ventilation on LMA and proceeded to secure airway via scalpel-bougie(finger)-ETT for transfer. I dont think waking up would be an option, given distances involved and potential for further drop in GCS and inability to protect airway.

    But this case highlights (for me) the importance of being able to manage the unexpected difficult airway in any place where elective and emergency anaesthesia is performed.

    My survey of rural docs in Oz suggests that not all of us have access to the kit required, nor the algorithms (see paper here or chat to me at the forthcoming #RMA2012 conference in Fremantle)

    ANZCA has a professional standard PS56 on the equipment needed to manage difficult airways. I am a fan of the UKs difficult airway society algorithms with clear plan A, B, C and D. Note that each of these steps requires specific kit to manage each of the steps.

    So, what do we need?

    Plan A – intubate the trachea, maximise first pass success

    DL (but if anticipated difficulty consider VL as first line).

    Max three attempts (2 in RSI).

    Change posiiton, blade, operator.

    Very few rural docs have access to VL. This will change…

    You mentioned that another GP-anaesthetist was called in to have a look. I’d emphasise the dangers of repeated attempts at intubation. If you remember nothing else, remember this :

    “Airways are like willies — the nore you fiddle with them, the harder they get”.

    Trust yourself and colleagues. If it was a grade IV view for DrX then it is likely to be so for DrY (assuming not a novice or ocasional intubator). Start to plan for alternatives, such as…

    Plan B — alternative intubation plan (omit if true RSI ? we can debate that one).

    Use LMA and alternative intubation plan. Jimmy D gives excellent approaches. Important to consider early use of the newer intubating LMA devices rather than classic LMA…

    Most rural docs have cLMA only. But less than 70% had proseal or supreme LMAs. Similar numbers had an intubating LMA (iLMA) to allow passage of an ETT blindly. You mentioned FastTrach…a good device but can be fiddly to remove the LMA once ETT secured.

    My approach (and Minh I think you would agree) is to leave the whole thing in place for transfer. I am a fan of the newer AirQII — combines the gastric drainage of a supreme LMA with the ability to intubate like a FastTrach, but a less hyperacute angle to navigate. About A$30 each with the oesophageal obturator/drainage tube.

    Whatever, I would be placing an iLMA early rather than a cLMA. But you need to have the kit!

    Of course, can increase ease of intubating through the iLMA using some sort of fibreoptic device…there are affordable options out there, with both (disposable) flexible scopes (five in a pack) or sterilisiable malleable fibreoptic stylets…all for around A$2500.

    Very very few rural docs have access to these…even though they are pretty much mandated at Plan B in the DAS algorithm. Of the two, a malleable stylet is easier to learn to use on mannikin, then elective lists — and allows visualisation of the cords to pass ETT through the iLMA as conduit (wont work thro FastTrach, too much of an angle).

    Use a Parker tip ETT to avoid arytenoid hangup.

    Plan C — maintain oxygenation, wake up

    As in the Bromiley case this can be forgotten, especially in a crisis.

    Following a recognised algorithm reduces risk of target fixation (“gotta intubate the trachea”).

    Only 40% or less of rural GP-anaesthetists surveyed were using such an algorithm or checklist. Time and time again from Coroners reports and closed claims, such target fixation leads to catastrophe. We are humans who will err. There are recognised algorithms. Use them.

    I agree though, waking up may not be an option here — she needed airway securing and faced a long aeromedical transfer with risk of further drop in GCS. So, here’s the question — if you were faced with this case again, would you consider using rocuronium at 1.2mg/kg…commits you (and the team), but means less chance of an unparalysed patient struggling through a surgical airway. Very few rural docs would have access to suggumadex, but one could argue is academic — needs a tube, either above or below the cords and one should have plans for this before start. Which leads nicely onto…

    Plan D — rescue techniques for CICV

    BroomeDocs has covered ‘needle vs knife’ debate about a year ago. Practical hands sessions in both dry and wet labs give us the skills to manage these infrequent but serious events.

    The kit needed is not expensive — a few hundred dollars at most. Scalpel-bougie/finger-ETT works for me (n=4) and Heard’s mob in WA are to be commended for bringing rigeur to this situation (check out their youtube clips)

    Bottomline — this sort of scenario can and will occur in small country hospitals. Not often, but it will happen.

    The rural GP anaesthetist will have to manage it and needs appropriate equipment and cognitive aids (algorithms/checklists/ongoing training) to do so without immediate specialist backup

    Affordable and robust equipment is out there for under A$5000 and there is really no excuse not to have it.

    Economies of scale are to be had by purchase in bulk (pref by State health depts) and recycling kit between rural and metro areas before expiry date.

    Use of similar equipment between sites and agencies (country hospital-retrieval service-Metro ED) allows for familiarity as personnel rotate as well as skills maintenance etc.

    That is all


    • Tim, this comment has been bigger, better and more fabulous than the actual post!

      I like you am always a little frustrated by the clinico-political limitations of rural practice. We always end up getting the new drug, new kit, new building – but there is an inexplicable 10 year lag…..

      Great tips. With this sort of drive we can take “city care out there” to steal an idea from @emcrit

      Looking forward to meeting up in Freo next week – will have to be on best behavior Dr L

  6. “City care – out there”

    Hot damn, I;m going to need to make a T-shirt

    Only one caveat – does that mean an 8 hr wait in my ED from now on?

  7. Maybe “specialist-level care, out there”

    My wife reckons that despite our ‘Jack of all trades, master of none’ tag, rural docs actually de
    Iver a bespoke medical service (within their limitations) rather than the sausage-factory impersonal chrning nature of the big city hospitals.


  8. Casey, I think that the conditions you described as to when to shift to surgical airway are appropriate–when your interventions are not working, and there are signs of losing the airway. Diminished tidal volume, stridor, decreased SpO2—you must change gears and make a relaxing incision in the CT membrane.

    Tim, let me add this. I have determined that with the fiberoptiic Stylet, I can intubate 5 ways:
    1. Alongside DL
    2. Alone (retro molar or midline)
    3. Through an SGA
    4. Via Cricothyrotomy
    5. Retrograde (theoretical at this point)

    You can inspect engines with these things. They take a lot of practice though, so they may turn out to only be useful through SGAs in the future because the SGA takes you all the way up to the doorstep in this technique, and the other techniques require relentless practice. Using a SGA this way does require learning—the challenge to me is to create a training video that shows the movements necessary to take all the force out of this technique. This technique fails when the endoscopist uses force–the endoscopist gets lost quickly, imparts an unintended bend in the Stylet contrary to the shape needed to achieve the procedure, etc…. It is an interesting experience to teach new endoscopists (or board certified anesthesiologists) a technique in which the use of force is not only prohibited—it is counterproductive.

    I’ll get started on my monograph today!

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