Rob got permission to share:
30 year old male with past history of SCC of the tongue at age 14 who presented with cough, and dyspnea with concerns for recurrent pneumonia. He was still on antibiotics and steroids after a recent hospitalization for pneumonia.
His cancer recovery was hampered by osteo-radio-necrosis of his jaw, and he was left with a scarred larynx, baseline trismus with incisor to incisor distance of <2cm, and some thickening of the anterior neck tissues. He had a G-tube for feeding.
He had normal room air sats, no stridor, productive cough and no fever. Chest Xray was normal, and he was considered safe to go home and follow up with his pulmonologist the next day. The family was nervous about going home so he was observed overnight in the ED.
A very specific discussion was has with the patient regarding the challenges emergent management of his airway would represent:
“I love to manage airways, but your airway scares me, and I would never want to be the one to intubate you”
“If you have an airway emergency on the floor, it would take longer for someone to cric you than if you had an airway emergency at home, and had to present via ems and have a surgical airway performed in the ED”
He was discharged from the ED the next morning with some racemic Epi to try at home.
He represented 4 days later in respiratory distress with 36 hours of ‘anxiety’ symptoms that had not been helped by escalating doses of benzodiazepines.
No fever, no cough, very hoarse voice at home.
HR 140, BP 160/110, RR 29. Sats 86% RA, 98% 15L NRB
Altered, sweaty, moving minimal air, and non verbal with significant stridor.
Racemic epi nebs,
125mg solumedrol iv
Glycopyrollate 0.2 mg iv.
Lido 4% neb.
VBG: pH 7.17, pCO2 104.
Anesthesia was called for Awake FiberOptic Intubation (AFOI) if a trial of BiPAP failed. Due to concerns that NIV could worsen his laryngeal irritation, or that giving Ketamine to help him tolerate the BiPAP could cause laryngospasm (est 1:200 risk) BiPAP was not started until anesthesia was present and ready to perform AFOI.
Anesthesia presented promptly and agreed with AFOI plan after BiPAP.
Beside table was set up with 4×4’s with betadine, trach (6.0mm), pocket bougie, and #10 blade scalpel, and gloves. Lido 1% w epi was prepared.
Pt kept at 20 degrees HOB elevation, NC at 15L, then BiPAP at 15/5 was started with no decrease in his work of breathing.
3 AFOI attempts were made, with each attempt aborted once sats hit 90%, the patient was hard to bag due to laryngeal stenosis, but with assisted spontaneous ventilations additional attempts were considered appropriate.
The neck was palpated, and prepped prior to first AFOI, and injected w lido w epi after 2nd AFOI.
3rd AFOI was with glidescope assist. Glidescope could barely fit into the mouth, and there were no obviously recongnizable laryngeal structures.
During 3rd AFOI cricothyroid membrane was punctured with 27g needle on the Lidocaine with epi syringe and air was aspirated to confirm location.
The patient received 1mg per kg Ketamine iv prior to incision for cricothyrotomy.
With sats of 92%, a midline 3cm incision made, then horizontal incision 1.5cm through the cricothyroid membrane. There was a small spray of blood and air, and audible air movement was present in the wound.
A Bomimed Pocket bougie was placed with some digital guidance, and advanced into the trachea. No tracheal rings were obviously palpable, and I did not forcefully check for bougie holdup.
A 6.0 mm external diameter Shiley trach was railroaded over the bougie, with some hangup at the skin level, it was then advanced with firm pressure into the trachea.
Oxygen saturations were 68% at time of Shiley passage, 25-30 seconds after procedure start time. Airway confirmation was with ETCO2 detected immediately, good breath sounds and chest rise, and rising oxygen saturations.
Post intubation analgosedation was with fentanyl bolus and drip, and propofol.
Holy Sh-t, Right!!!
Update: See this amazing story posted on G+ Community as well
Now, on to the Wee…
- COVID19 – Awake Pronation (aka the Pig Roast) A guest write-up by David Gordon, MD - April 6, 2020
- EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilation of COVID19 Patients - April 4, 2020
- EMCrit 269 – Rationing of Critical Care and Ventilators in COVID19 with Reub Strayer - March 31, 2020