How would you manage this airway?

[MmacFN]

Hey everyone.

Ok. While my environment is different from the OR, this question is still valid.

If you have a patient who:

- had a severe head injury (grey matter visible),

- severe bleeding into the airway, unclearable by suction,

- Difficult to BVM do to severe lower jaw fx/instability and tear in the skin under the mandible. Sat = 78% with bagging

Would you choose to:

- Cric

- Nasal

- Blind attempts

- ILMA/Combitube

- Something else

Would you use any induction agents? Sedation, paralytics etc

- What if the patient had some degree of trismus? Then what?

Thanks

[burn out]

First what is the setting, in the field or in the hospital?

[Focker, CRNA]

I can't thing of what BVM (bag-mask ventilate?) stands for but I'm assuming its similar to a jaw thrust. But it does sound like you are somewhat able to mask ventilate him. I would think that a fastrack or combitube would be the first thing you would try after a quick blind attempt with laryngoscopy and succ. With the combitube, shouldnt matter whether you hit esophagus or trachea, you should be able to ventilate if there isnt overt damage to the airway, right? In that situation if the patient isn't spontaneously breathing I think a blind nasal would be difficult, plus, probably contraindicated with the massive head trauma. If those didnt succeed I suppose you would be forced to go with emergency cric. Trismus (lockjaw, I had to look it up) would indicate succ if you thought you could ventilate for the time the patient was paralyzed if you werent able to secure the airway. With the trismus, if you couldnt do a nasal intubation, and didnt want to give succ, and the pt. is 78% and dropping seems like you would have to go with cric. Etomidate for induction agent, given the pt. is probably hemodynamically compromised, if you used anything at all?

By the way, I'm just a first year student, so I'm sure I left a bunch out and maybe got parts wrong, but I figure if the more experienced people here can correct me, I might learn something.

[yoga crna]

Mike,

I would make a quick attempt to do a blind nasal, but if there is any resistance, I would stop. Blind nasals are easier if the patient is breathing, otherwise it is good positioning and luck.

Then I would try a fastrac, if you can get in an LMA. A cricothyrotomy would be another option.

When you give a muscle relaxant to a patient like this, you better make sure you can get the tube in or else there can be issues of aspiration, inability to ventilate and the infamous slippery slope.

I'm happy my days of making those choices are over. We don't see that in plastic surgery. It is good experience for you young guys.

Yoga

[Nathon]

Mike,

I would make a quick attempt to do a blind nasal, but if there is any resistance, I would stop. Blind nasals are easier if the patient is breathing, otherwise it is good positioning and luck.

Then I would try a fastrac, if you can get in an LMA. A cricothyrotomy would be another option.

When you give a muscle relaxant to a patient like this, you better make sure you can get the tube in or else there can be issues of aspiration, inability to ventilate and the infamous slippery slope.

I'm happy my days of making those choices are over. We don't see that in plastic surgery. It is good experience for you young guys.

Yoga

NEVER do a nasal tube with a person that has grey matter coming out!!!!!! Unless your goal is to insert the tube into the BRAIN!!!! Any type of head truama a nasal tube is containdicated until head ct or exray confirms that there is no scull fracture

[yoga crna]

NEVER do a nasal tube with a person that has grey matter coming out!!!!!! Unless your goal is to insert the tube into the BRAIN!!!! Any type of head truama a nasal tube is containdicated until head ct or exray confirms that there is no scull fracture

Never say NEVER or ALWAYS when it comes to anesthesia. You have to make the tough calls many times and they will humble you more than once.

yoga

[UCDSICURN]

Here goes my layman's attempt (Not a CRNA or SRNA).

I wouldn't go nasal due to the great possibility of facial trauma/sinus injury.

Due to the patient already being hypoxic, I'd go for the old combitube due to the blood not being able to be cleared by suction. If was clearable, I'd go fiber-optic. Will probably need facial surgery so he/she may end up being trach'd anyhow by the ENT guys. I wouldn't use paralytics unless absolutely necessary.

That's my shot, based on my rudimentary(sp?) airway management skills/knowledge. Just tried to common-sense my way through it at 1am.

[gregemt]

would try combitube if unable to intubate, if this didn't work, cricothyrotomy. This is in the field, don't know what I would do with all of tools available in hospital setting.

[jwk]

"unclearable by suction"? I might try a fast-track, but probably would very quickly move to cric this patient who is quickly heading towards the light.

"I see Blue - he looks glorious" Sorry - "Old School" was on TBS all weekend.

[Tenesma]

if i see gray matter i would place an IV, hydrate them w/ some morphine and let the family say goodbye with a lot of bandage on that pts head/face...

[flashpoint]

Depending on the degree of trismus, your only option might be a cric. I would be pretty hesitant to do a nasal or a blind and (again depending on the degree of trismus) you might not be able to get a Combi-Tube or LMA in...Combi-Tubes are BULKY!

I think Tenesma has a good point...the most humane thing to do might be to slip in a line, push some morphine, and provide support to the family as they say goodbye.

[susswood]

Yeah, grey matter is coming out... but you would still tube and ventilate in an effort to save the viable organs for donation.