a difficult airway…
The Case.
The ‘Batphone’ alerted us of a 68 year old female who is postictal following two seizures in rapid succession. She has a history of ‘a brain tumour’.
P 120. BP 176 systolic !! GCS 8/15. Afebrile. Sats 98% (15L NRB + guedel airway).
She arrives direct to your resus bay 4-5 minutes later and she is actively seizing.
A) Obstructed (Guedel on floor). Trismus ++.
- Bilateral nasopharyngeal airways inserted
- Two-handed jaw thrust
- Ventilating well on 100% BVM.
B) Bilateral air entry. Sats 99% on O2. No added sounds.
C) P 130 (sinus) BP 185 systolic. Diaphoretic. Warm peripheries.
- 2x IVC inserted
- 500mL N.Saline bolus
D) Actively seizing (GTCS with movement in all 4 limbs). Pupils 4mm (L+R).
- 2x 5mg IV Midazolam (seizure resolved)
- 1gram IV Phenytoin (loading commenced at cessation of seizure)
E) Temp 37*C. BSL 13. No rashes, contusions etc.
Impression:
Status Epilepticus (3x seizures with no return to normal mental state)
- ? secondary to ‘brain tumour’ or associated haemorrhage
- No other medical history available
- “Family are bringing in her medications”
Following resolution of her seizure she remains obtunded, GCS (E1V1M4) 6/15 and still obstructing her airway. A decision is made to RSI for airway control and prevention of secondary brain injury, followed by urgent CT.
The Issue.
This patient is short, obese & has barely got a neck (soft tissues ++).
What neck she does have, has minimal range of motion.
Her mouth is small. Her mandible receded.
Our saving grace = she is surprising easy to bag-valve mask ventilate with just one user.
The Plan.
Ramped position (close to 45 degrees). Ear to sternal notch.
PreO2 + high-flow nasal cannula.
Standard RSI (we used Thio & Sux)
C-Mac video laryngoscope + bougie + size 7.0 ETT
Size 3 LMA supreme (opened & tested).
Whilst we did not verbalise the plan for a surgical airway in this lady, one ED physician nearby did come to the bedside and palpate the anterior neck prior to induction. Certainly I recall knowing what his intentions where at the time…
The Reality.
As far as we were all concerned, we had optimal patient positioning from the get-go.
Thio. Sux. Go….
Size 3 C-Mac blade in…
As this is occurring I am recalling the mantra “epiglottoscopy before laryngoscopy”
… Well the epiglottoscopy was easy. In fact that was all I could see. One giant pale, fat & floppy epiglottis which took up both my DL view and the entire C-Mac video-screen.
- I visualised the laryngoscope blade into the vallecula but due to anatomical difficulties, I could not lift the blade/scope. I could not see the arytenoids. ELM / BURP made no difference.
- I attempted to advance the blade beyond the epiglottis in attempt to ‘pick it up’ however the large curve of C-Mac and her narrow airway made this impossible.
- So I withdrew the blade, reapplied O2 via BVM and found that again she was easy to bag-valve mask ventilate.
- Concerned, but calm.
Considering our options, whilst searching for our Miller blade I am handed a standard Mac-3 to have another go…..
- Same story. Big epiglottis. No view. Can’t pick the damn thing up…
- I took a bougie and attempted to lift the epiglottis with that. Same result…. No view.
- I made a single attempt at a blind bougie pass which was clearly oesophageal, so again I withdrew & again she was easy to ventilate.
- Sats have remained at 99% throughout.
- I hand the duties over to my supervising physician & take over the team-leading role….
As it pans out; there are three further attempts at direct & video laryngoscopy. With each further attempt there is more & more blood pooling in the oropharynx. There are two attempts of intubation over bougie (both oesophageal). During the first two of three attempts, the patient was still incredibly easy to ventilate and her oxygen saturations did not fall from 99%…..
The Finale.
Following the final attempt at an unsuccessful intubation, her saturations plummet from 99% to 60% to 50% in a period of 4-5 seconds. There is a two-user attempt of BVM (me with two hands holding mask to face with jaw thrust & Consultant #1 on the bag).
- Oxygenation does not improve. I call for my LMA & Consultant #2 sprays the anterior neck with Betadine…
- As I insert the larygneal mask, the surgical airway kit is opened on the patients chest.
- The LMA is in with oxygen saturations of 16% !!!!! (Heart rate ~ 110)
- I have three squeezes on the reservoir bag (1, 2… uh oh; bag is rigid and will not ventilate)
- I announce to the team that we can no longer ventilate from the top end.
- The nod is given to Consultant #2 who takes scalpel to neck and as finger is placed within the trachea (before the Shiley is inserted) I am suddenly able to ventilate into the chest from the top end…. Sats jump into the 90’s.
- The Shiley is secured.
The Outcome.
- ENT arrive and are happy with the airway for now. They will look at it formally in the OT tomorrow….
- CT-Brain demonstrates a complicated meningioma involving the right cavernous sinus (a little worse than last scan), but there is no haemorrhage.
- Her family arrive and hand me her medication bag. The first box I take out is…….. Warfarin !!!! (Recently diagnosed PE).
- She has a smooth course in the ICU and at day 7 is reported to be back to her normal level of consciousness.
The Reflection.
I have found myself analysing and reliving this case over and over since it occurred (now, well over a 6 weeks ago) for many reasons.
- It was my first failed intubation in the ED for over 3 years.
- I was enjoying a purple patch of airways.
- I needed this case to avoid complacency with ED airway.
- It was my first involvement in an emergency surgical airway.
- I had (and still have) swinging emotions between failure and success.
- I felt I had failed this patient with my inability to get an oral airway
- As a team we were successful in our ultimate goal and she had not suffered for it.
- I want to do better next time…
I have come to the conclusion that as a team we did a number of things well. The set-up for the intubation (including pre-oxygenation, optimal patient position and ongoing apnoeic oxygenation) gave us the best opportunity for success from the first attempt. We not only recognised a patient with a predicted difficult airway but had discussed our difficult airway algorithm and back-up plan aloud prior to induction. We successfully moved through our algorithm and (eventually) placed a endotracheal tube to secure a definitive airway.
The retrospectoscope is a power tool and I know there are certain things we could have done better. Had I known this patient was on warfarin, there would have certainly been less blind attempts at passing the tube. In fact, I would not have persevered beyond a second attempt at laryngoscopy. I am convinced the progressive airway bleeding was the tipping point in converting a “can’t intubate, CAN ventilate” into a “can’t intubate, CAN’T ventilate” situation. I believe there was a blood clot within the trachea that blocked my ability to ventilate with the LMA and it was dislodged with the placement of a finger in the trachea on cricothyroidotomy.
If I could play this scenario through a second time around, I would hold back after the second laryngoscopy attempt and either place an LMA or continue the easy BVM-ventilation. A fibre-optic intubation would have been wonderful here and in our shop, this would have bought us time for Anaesthetics to arrive and facilitate that for us. Whilst we recognised that this lady was going to be a difficult intubation we did not actually verbalise the potential need for a surgical airway prior to induction (and proceeding to this made some staff uneasy). If there is a next time I would have prepped her neck ahead of time and marked out her cricothyroid membrane with a pen.
When discussing my airway algorithm aloud prior to all subsequent intubations, I now include surgical airway as a finale and the kit is bought to the bedside within arms reach.
I will no longer let perseverance get in the way of our ability to oxygenate and ventilate.
I would be interested to hear your feedback or comments on this case that still has me pondering, “What if ?”.
Chris.
