thanks Scott Sorry to hear Janus General colleagues/admin were not so supportive of the hypothetical case management here. You are correct in that surgical airway is a dying skillset. Levitan said it is now regarded as a sentinel event rather than a part of reality of emergency medicine /emergency airway care. The proliferation of VL and other technologies has further cemented the notion in our collective minds that all airways can be managed non surgically. It is notable as in this case that it cannot prevent all surgical airways I dont think you should change your overall approach and what you teach. I appreciate however peer review can bear on ones mind and can affect how we perform in future . One suggestion for future is to stock LMAs that blind intubation can be performed via. The favourable capnography once the LMA was placed , indicates there was a good chance blind intubation would have been successful via the device. in the absence of this, proceeding to surgical airway in patient with critical desaturation seems reasonable . Please do not ignore the valuable contribution to medical education and surgical airway training that you and your work has provided to the… Read more »

Thank you for another outstanding talk. What a perfect distillation of the concepts you’ve been teaching that have saved so many lives. Unfortunately, the vast majority of physicians outside the FOAMed community seem to believe that every patient deserves a trial of PEA arrest prior to cricothyrotomy. We know better, and must still do the right thing regardless of the emails that follow.

Scott,
Amazing cast. I’d say if you don’t at least occasionally agonize, you’re not a true Resuscitationist.
Leaning towards surgical airway will save many more lives than leaning towards “making sure we’ve tried everything else”. We MUST be confident: mentally, logistically, and physically prepared to perform the Surg Cric from the very beginning of each & every airway we take into our possession and control. Having said that, questions I have for you: Do you have intubating LMA’s @ JJ? If not, do you guys have, and/or is there preparation for:bAintree/LMA/Fiberoptic? Regardless, do you have the Fiberoptic plugged in & at the ready for every ariway/(difficult airway)?

-Sam

First off, great podcast as always. I absolutely love your approach to teaching and have used so much of this to reinforce my own skill set. The case you bring up would make my hair stand up as I have never done a surgical airway despite being in 19 different hospitals over several states as an ICU guy. You ED heros usually take care of this stuff for the patient before I need to get my little paws all dirty. However, there are times when my airways become a real challenge in the unit. The Monday-morning quarterbacks that sit on peer review will always have hours to mull over the 10 minutes of hell we have to endure when things go south. I think you are right on the money when you say that we are second guessing our colleges and students out of doing the right think sometimes because it is a less than usual outcome. We are expected to be perfect all the time and have no “complications.” I have taken a lot of advice from you and after working with some really senior anestheisa folks –that are exceptional at critical care — I have changed my intubation… Read more »

Happy New Year! Very nice case and analysis. A few thoughts: -Preparation is key. In the OR, when I work with ENT (see NAP4 data) I verbalize a plan A, B, C, and sometimes a D. This drops the energy level in the room and facilitates smoother care. -To reiterate what a previous contributor asked, did this ‘patient’ have a known potentially difficult airway? If so, then awake FOI is the standard of care. Otherwise your algorithm was ok. I’m not sure I would have gone for the 3d look w/ the Miller if the pt was de-satting and I had no view with the MAC3 with a video view, but that’s just me. Especially with pts s/p head/neck radiation, sometimes these folks will bleed like stink even after a simple DL. I always always advocate: “don’t f*&k up the airway and make a bad situation a life or death one”… -LMA is underused but is literally a life-saver. I particularly like the Cook-Gas intubating LMA, which I can throw in while waiting for a fiberoptic scope. However, LMAs are not fool proof, as the NAP4 data illustrates. Where they fail particularly is in infraglottic/glottic lesions. They are only designed… Read more »

Hey Scott, I’ve recently become a huge fan of the fiberoptic LMA technique (fiberoptic/aintree/LMA if no intubating LMA). Through conversations with my colleague & good friend Andy(Sloas), and through practice, I’ve come to realize the true power & potential of the technique. As you know Andy would prefer to intubate all comers in this fashion (directly to RSA and fiberoptic from there), and although I don’t think we should necessarily be doing this for every single intubation (for various reasons), I do think it may be the wisest approach in select cases. Even if not directly to RSA on first attempt, I’ve come to lean towards moving the technique up in the airway algorithm. It may serve to be prudent earlier on in the intubation, when the O2% sats are more stable and consistently higher, and when there’s less airway edema, maybe even as early as after one failed DL/VL approach where the patient goes hypoxemic and now you must re-oxygenate. I generally have a very low threshold to bypass the BVM and go directly to LMA anyway for re-ox. Taking a look down the runway with the fiberoptic seems like the logical next step, especially if DL/VL gives any… Read more »

Great case grippingly presented. We all could have been there. Ironically, had an anesthesia or emergency resident given a bolus of propofol and the patient arrested on induction, then in all the hospitals I’ve worked he would have been pronounced dead with the cause attributed to his illness and no further investigation or criticism would have been likely. However, in your hypothetical case at JGH, your meticulous preparation, resuscitation, and pre-emption resulted in a surgical airway being a viable option and he made it to ICU alive with a good airway, and as always the downstream providers made fundamental attribution errors based on an assumption of emergency physician ineptitude. We agonise over every airway presented at our monthly airway audits at Sydney HEMS. Some points I’ve taken away from that and my own experience that MAY have slightly altered the path (but not I suspect the destination) here are: (1) ‘Blind’ bougie attempts (ie. no clicks or hold up) almost always result in oesophageal intubation. I wouldn’t pass a tube over a resident’s bougie if there were no clicks or hold up, due to the strong likelihood of significant desaturation in this patient with an even-rapidly-identified oesophageal intubation. (2) If… Read more »

Scott, you are incapable of doing a ‘cast and not teaching me something. As I scanned the show notes before listening, I thought to myself: HOP killers, difficult airways, crics: now HERE’s a ‘cast in my wheelhouse. And then I listened, and I learned. I’ve never done inline waveform capnography when doing bag mask ventilation. For some reason, I’ve had a mental block whereby I’ve always reserved the inline capnography for post-placement of either ETT, SGA, or cric. But as you rightly point out, when doing BMV, it’s tough to tell by just feel and watching chest rise how successful you are at ventilating. Thank you for that tip.

NONE of us will ever get enough physical practice at doing crics. We can and must endeavor to get as much physical practice as possible in the sim lab and the cadaver lab, but it’s never enough to completely remove the fear that makes people start crics too late. The one thing that can do that is disciplined MENTAL practice (visualization) on a daily basis. It’s gotta be part of a pre-shift ritual.

Dr. Weingaert, As usual, I enjoyed you podcast. The sweat on my palms made me realize that I could place myself easily in this situation. I work as a PA in a remote environment where emergency airway management is a very rare thing to deal with. But, as anything can happen, and with a population of patients with many severe and potentially severe co-morbidities, I still have to be prepared. I have found much inspiration in your talks to look critically at my set up and, more importantly, my mind-set. Thought experiments like this have pushed me to better prepare myself and my volunteer team to assist someone in an airway emergency. I use these as tools to put the patient in my resus area and play out the worst case scenarios. Your airway and cric talks have inspired me to push past what is expected of me into what is the best possible care that I can give, then what i can do to improve that. I have changed my mindset and will continuously prepare for the emergency airway, and have a knife, bougie and finger ready to do what needs to be done before the worst happens. Your… Read more »

I think it can not be said enough that preparation is the key in these situations. The method of getting the airway can be up for debate to some degree as you all have noted above. In the end getting the airway by whatever means saves the patient. I learned the hard way one time when I asked the RT for a bougie and they looked at me kinda funny. I am a full time locums so every new hospital brings new challenges and variance with practice comfort by the teams in work with. Preparation for such things is paramount. The checklist approach is awesome. I try to be prepared every time I do an airway. As I have been surprised how the patients that seem like they may be easy can be very difficult once you start entering the airway. One question I had though. What is the role of so called “reverse intubation?” I have seen vids of this on youtube and wonder if it is less useful. I can see how it would not be useful for say a mass around the cords for example. Is it something that has fallen by the wayside or less effective… Read more »

well…if folks are bringing up all sorts of airway techniques like retrograde, FOI via LMA..I think its prudent to remind ourselves of KISS principle. Blind intubation is , like surgical airway skills, a dying art. It was de rigeur in the past for ENT lists, Dental lists to do blind nasal tubes daily, with bottles of CO2 to induce hyperventilation to assist the procedure. But that is in spont breathing patients..so maybe not so suitable for this hypothetical case! Blind nasal as a rescue technique is terrible. patient is usually apnoeic so no guidance as to if in right direction! BAAM device wont work! Neither will capnography so that leads to a really lost art of blind digital intubation. it works! not all the time, but as a rescue technique its hard to beat!! dont need any special gear! would it have been possible in this case as a rescue technique? maybe! I have had two cases whereby it rescued a CICV. situation I know many disregard it now and it is virtually never taught but the anatomy is not difficult to learn and the technique is not complex. there are some risks but in CICV, prob less than wielding… Read more »

Great case that gave me flashbacks to my most recent cric.

A couple comments,

1. Fortunately, not all hospitals look at a surgical airway as a Sentinel Event. In fact at my facilities I have never been criticized for my airway choices or performance. Even my most recent “cric”. Which turned out to be a supraglottic or sublingual airway, which was necessitated by comlete calcification of the cartilaginous and membranous structures of the neck.

2. Not all EMS medical directors consider a surgical airway a failure. Howeve, many medical directors are familiar with the “hero” mentality of some ems providers that affect the decision to perform a surgical airway. When 1 in 100 provides account for >80% of your surgical airways, well, you have to question the decisin making.

3. As was pointed out earlier, we will never get enough experience with surgical airways. This is especially true of HEMs providers. Most HEMs providers manage <15 airways a year which is barely adequate for "normal" airway management, much less the difficult airway.

Thanks for the awesome 'cast. See you at SMACC

Mike

Wow… great podcast!

I can’t agree with you more.. it’s a dying skillset that scares the heck out of most providers. The only way to be ready is learning from situations like you described, mental preparedness, and hands on practice whether that be simulation or by cadaver. The latter is hard to obtain for the average provider.

While I’m genuinely heartbroken that I probably won’t be able to attend SMACC; however, I was able to attend CCTMC this past year and participated in the anatomy lab, in which Bill Hinckley (who’s comment I saw above) lectured on Cricothyrotomy. Forgive me if I misquote you Dr Hinckley, but “we all have the best simulator available between our ears.” Whether or not your intent was to create that same mental practice/imagery, you did a masterful job! You could do a whole series on medical imagery education! I felt like I was there experiencing it first hand… Keep it coming!

RE: 141 (airway at Janus General w/ 45 y/o male w/ sarcoid).

Extremely nicely done.

I was sorta on the fence about re-upping for CME membership until I heard this one. Got on it today.

Jim Carroll, CRNA
Wisconsin

Good job on this Scott. Great case with great teaching. Also good discussion on the professional fallout of doing a surgical airway, i.e., the harassment that can occur in their aftermath. Let me add this encouragement to your lecture–always do the right thing. You may need to “justify” the cric after the fact, but if you were doing the “right thing,” it will be easy to explain–just tell the truth, just tell it like it is. I provided anesthesia recently for a patient in severe liver failure in an outside procedural area (a portosystemic shunt). Going through your case reminded me of the steps I took when managing this case. Patient was fragile enough that it became clear that an arterial line was required to closely monitor the blood pressure during induction. IV sedation, ultrasound guided arterial line one attempt. The vital signs were marginal as indicated by the arterial line–vasoactive support drip started prior to induction. Careful induction with generous rocuronium dose, easy intubation. The point here is…take the steps to ensure that safety can be maintained within a reasonable margin–don’t skip over steps or make irrational choices, like repeating an unsuccessful approach ad nauseum. One of our next… Read more »

Wonderful talk Scott. These points are so important and under appreciated. They must be more widely disseminated. Also excellent solid physiology basis. I agree with using the devices with which one has the most experience. Intubation over a broncoscope through either the nose or mouth is my preferred method. While learning intubation through the nose over a bronch in a large patient is very easy (but may limit tube size). Intubation through the mouth over a bronch takes very much practice esp with patients with large tongue and limited velo pharyngeal space. I have a few questions. First what is everyone’s thought on low blood bicarb. pre-sedation for intubation . A patient with a bicarb of 14 and a spontaneous PCO2 of 18 may have a normal pH (have to run that through HH equation to be sure) but with sedation/paralysis the pH may drop well below 6.7 within a very short time and that level of compensatory hyperventilation will be impossible to maintain if the first pass intubation is not successful. The second is dynamic hyperinflation. Patients with COPD and asthma are at risk for this and it can induce sudden PEA or hypotension immediately after intubation in some… Read more »