Cite this post as:
Scott Weingart, MD FCCM. EMCrit Wee – A Cric Case with Rob Bryant. EMCrit Blog. Published on April 24, 2014. Accessed on April 26th 2024. Available at [https://emcrit.org/emcrit/cric-case-rob-bryant/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: April 24, 2014
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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What was the difficulty with the AFOI attempts? Could not see laryngeal inlet? Could not pass vocal cords? Would a transtracheal catheter have provided more oxygenation and time for FOI attempt?
Anesth. could not see laryngeal inlet. I couldn’t see anything recognizable on the glidescope screen on the 3rd look. There was a total of an est. 8 min of FOI attempt, there was no request for another look from anesth. after 3rd look when I said we should proceed to cric.
ROB IS THE MAN! way to go , mate!
It is almost a year since Scott helped me with the Difficult Airway course for Critical Care physicians since then I have done 5 surgical airways. We are preparing to have another course and refresher, it is amazing how many individuals who believe are experts on the airway have not done surgical airways or even practiced how to do this.
Great case, I guarantee your case takes anyone who has had to perform an emergent cric right back there. My last one was an inhalation burn case, and I promptly needed to head out to ambulance bay for a moment of recovery. I think we need to get together an EM surgical airway registry. They are rare but we do them. Depending on the anesthesiologist, they are often less prepared mentally and practically for this scenario than we are. I had a question. Was there any discussion of an attempt that did not involve AFOI off the bat? Maybe RSI,… Read more »
He had extremely poor mouth opening, I was surprised that the glidescope was able to fit. In a do-over I would consider trying a right paraglossal look with a miller blade. Most of my mental energy was spent on prepping for the surgical airway, and AFOI was the only realistic option I considered from above. I am glad we did not paralyze him given the difficult time we had bagging him while spontaneously breathing.
Rob I think you made the right call. Anatomy appeared far too difficult to risk paralyzing — that’s the second most important decision we make in airway management (first is the decision to intubate, of course)
Interesting case. Must have provoked some visceral feelings… Did you think of involving ENTand doing the pprocedure(s) in thratre?
Interesting case. Must have provoked some visceral feelings… Did you think of involving ENT and doing the procedure(s) in theatre?
No we did not call ENT, he was profoundly unwell, and I did not think we had time to wait for ENT to perform the procedure in the OR. He was looking sicker (increasing HR, decreasing responsiveness) in the 20 minutes we spent getting everything set up before the AFOI attempt.
Great work Rob – go Kiwi!
Chris
Amazing case, thanks for sharing & great discussion!
This case highlights one of the drawbacks in “calling for help” — sometimes the cavalry arrives without their horses.
In your case, it was just the breakaway bite block. But I have been involved in a number of cases the backup arrives with just a Mac 3 and a big syringe of propofol, despite going through some of the specifics of the case and specifically requesting advanced equipment (eg FOI).
we’re the AFOIs oral or nasal approach?
Oral, with breakaway oral airway.
I would like to comment that as a trained assistant to Rob Bryant, I had the Ketamine in hand and had asked for a Cric Con. Since, there has been a lot of training in our department; via conferences and “trauma optimization” this had a good outcome for the patient. Rob failed to comment on, how shaky his hand was and how he could have benefitted from some stabilization.