Cite this post as:
Scott Weingart, MD FCCM. Minh Discusses Three Examples of Airway Management gone Bad. EMCrit Blog. Published on August 9, 2011. Accessed on April 25th 2024. Available at [https://emcrit.org/emcrit/three-airway-disasters/ ].
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: August 9, 2011
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
You finished the 'cast,
Now Join EMCrit!
As a member, you can...
- Get CME hours
- Get the On Deeper Reflection Podcast
- Support the show
- Write it off on your taxes or get reimbursed by your department
.
Get the EMCrit Newsletter
If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the Resuscitation and Critical Care goodness.
This Post was by the EMCrit Crew, published 13 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.
Hi Scott. I was there at case III. Hence my mistrust of the needle- jet vent technique. Ultrasound might have been the only winning technique that day.
The main points to take from case 3 is – history of airway problems us the best predictor. Do an awake technique if in doubt.
For tricky cases ask yourself: what is plan A, B, c…. And am I the right guy for the job?
Thanks guys
Casey
For tricky cases ask yourself
Casey, you’ll have to speak to me about that case sometime; I would be fascinated.
Exceptional case studies Scott.
thanks Scott for taking the time and effort to research and post these cases. You impress me for having gone away and looked into each case I cited. I deliberately mention those cases as to me they demonstrate a couple of salient points about emergency airway management. Firstly you must diagnose the problem early and clearly. Declaring the emergency loudly and giving it a name will galvanise you and your assistants into necessary action. Secondly the last two cases in Perth to me illustrate the non inferiority of the two techniques. IN the Jankowski case yes indeed needle cric failed… Read more »
Hi Minh, I was there in the Rassmussen case. The needle cric-jet vent resulted in massive surgical emphysema, which then made any surgical approach impossible. This demonstrates the non-benign nature of needle cric, you can make it worse with a needle! As for my”opinion” about the best approach – well, I think this falls into the category of “suck it and see”. Essentially, that is what my / our job is – we train, we garner experience and we make critical calls on a minute – minute basis. Ask me how I know when to change a vent mode, or… Read more »
Thanks Casey Humans are mostly risk averse creatures. If anything the recent PE debate and Wall Street market crash demonstrate that! There is little point in telling docs they gotta do it this way if they perceive the risk to be too great I have two cases I know of where surgical cric went wrong. One failure but eventual successful orotracheal intubation on reattempt using bougie and one death due to misplacement of surgical cric Does that mean I mistrust the scalpel bougie cric or standard surgical cric technique ? no….but I have to try to learn how to improve… Read more »
If only this post would force us to remember and trace the steps of Bougie cric at the back of our mind, this single post could save lives. And we owe our patients to have this locked up in our armamentarium, even if only theoretically, but ready when the time comes.
This only shows how unfair to ask help from our anaesthesia colleagues on cases like this, they’re not trained to do this. And so, we should be.
Amazing, graphic cases! Thanks!
Another hot topic! Thanks again Scott. I feel more comfortable as a ‘knife-guy’ for two reasons. One is the simplicity of the equipment involved, and all reading this know that if there is going to be something missing or a ill-fitting connection, it happens when a patient crashes. Second, Oxygenation without ventilation in these already hugely acidic patients must cause some of them to go into PEA, even as we see the SpO2 rising. I guess it’s a hard thing to prove in what is a rare population, and I confess I haven’t looked for any cases of unexplained cardiac… Read more »
i’m with you buddy
Thanks Scott and Matt I appreciate there is disbelief amongst yourselves as to the efficacy of the needle cric technique Heard and I describe. I also appreciate whatever I might offer as testimony to its efficacy that disbelief will remain amongst many until you are having to deal with the situation for yourselves and what you choose to do I totally agree at least prepare and train for it religiously. There is no reason why you could not perform both techniques in rapid succession, by placing a cannula quickly and provide apnoeic oxygenation and then handing that off to an… Read more »
Minh, that’s a good point about the paeds, I hadn’t thought of that, I don’t really see it as a debate that anybody needs to win. A two-man team managing a critical patient in a pint-sized, pant-shaker chopper is a different ballgame to my academic hospital, where there are 5 guys and girls all gagging for the airway, safe in the knowledge that there are 4 back-ups should there be a hitch. Great podcast guys! I believe one learns best by forming opinions on a subject, making this a great forum for learning. Say hi to the newlywed Jase Peterken… Read more »
thanks Matt, I will pass on my regards to the newly wed Jason. Its coincidental but he had to tube a head injured 4 yo in a remote clinic a week before his wedding. Everything went fine but it is a reminder we should always regard all age groups in our thinking around emergency airway management and low resource settings I think Bruce Lee put it best when he taught “Your opponent decides your style of fighting..your technique must adapt to your opponent” How many of us would readily put knife to neck in the patient with impalpable neck anatomy… Read more »
well said!
Very compelling video, I plan to share it at an Airway class I am teaching this week with our Air Ambulance program. Airway training and practices vary so much from hospital to hospital, and EMS Program to EMS Program. I heard about an ER MD that told a flight nurse recently that Bougies are for wimps…two days later he couldnt intubate an obese lady? These discussions are wonderful and motivate myself and others to pursue excellence in our clinical practice. There really is no excuse for the first scenario, they were completely unprepared for failure, which in our field is… Read more »
the greatest warriors and tacticians in military history have always planned for failure. I don’t have much respect for a doc that would state, “bougies are for wimps.”
Thanks Jason
I agree with Scott. Thinking you are invulnerable from adverse events does not promote safety in clinical practice . Turning up to a gunfight with a knife (excuse the surgical airway pun) is a recipe for disaster
I was doing my journal reading yesterday and came across this excellent anesthetic article that encapsulates the major points we have been debating. If you can access the complete article I would recommend it’s worth
http://www.aaic.net.au/Document/?D=20101065
I found the first video the most compelling lesson of these cases. I’ll remember it when teaching student nurses about the concept of “silence kills.” It’s a great example of that. Thanks.
TTG, RN, CNS
thanks for listening, Teresa
Hi there, I’ve just recently started reading this blog and downloading the related podcasts off iTunes. May I just say what an incredible resouce these materials are; the sterling work of Dr Weingart (and contributors) is deeply, deeply appreciated. I imagine that producing such high quality material must take a great deal of time and effort, for, in all likelihood, minimal remuneration in return. That this is so only heightens one’s respect and appreciation for all of you. As to this particular post, I’ve viewed the video concerning the unfortunate case of Elaine Bromiley and did a little reading online.… Read more »
fantastic addition, I will add a link to this to the post
Thanks for the hard work you put into producing such quality podcasts. Know that you positively affect patient care on a global scale, far transcending your ED.
Hey Scott,
love your stuff. I think you are doing an excellent job getting rarely discussed issues out in a really accessible forum. As an Anaesthetic registrar in Sydney with a special interest in critical care and trauma these podcasts inspire those of us working at the cold-face to think more deeply and be more prepared. It’s someone’s mother, father, son and daughter and we should be at our best. So thanks.
Thanks so much, Tim!
May I echo Jim and Tim’s appreciation of the work you put into EMCrit , Scott? I do not know how many times readers have provided feedback on the practicality of your teaching to real world clinical practice but wanted to do so here. I learnt the concept of delayed sequence intubation from Scott and had the perfect opportunity to apply it to an actual critical patient on retrieval last Friday night. The lady was in pulmonary edema and going south despite NIPPV which she did not tolerate at all well. Anyway I used DSI to good effect and it… Read more »
thank you for those kind words, my friend
Scott, I am not sure you are aware of this airway management case in 2006, after Elaine Bromiley’s . It’s worthy of review by all airway practitioners as it has important human factors elements.
http://www.scotcourts.gov.uk/opinions/2010FAI15.html
Great additional case. Seems like equipment familiarity also played a role in addition to the human factors failures you mention.
Truly wishing for more detail about the first case. What were the induction medications, and why did she not begin spontaneously breathing after 1 or 2 minutes. Did the anesthetists use neuromuscular blockade with the propofol shown in the ‘reconstruction’ video? Other than providing a message of, “Gee, you really need to be prepared and always thinking of worse-case scenerios,” what’s the value of this video? There is no relevant detail allowing me to evaluate my own practices.
I think the link immediately following the video (investigation/coroners report) has all of that info and the take-home messages. Let me know what you think.
I understand the desire for more detail in cases like this. It is our disbelief that elective surgery and anaesthesia can result in such tragedy that makes us want to search for answers. We would like to be able to trust that our own practices would not lead to such results I think this misses the point. If an air line pilot tried to keep landing at their primary destination airport and due to bad weather kept failing AND they kept trying to do that until they ran out of fuel and crashed killing multiple passengers WHAT WOULD BE THE… Read more »