Airway management mishap results in tragic outcome - page 3
this is a cross-posting from ogp - and a tragic example of why the airway is not the most important thing, it is the only thing! also, an interesting question brought up on ogp: why was a... Read More
Oct 23, '05Quote from Athlein1We used stuff like this as Combat Medics in the Army. They're pretty cool and don't take a lot of skill to use.CRNAs can do emergency trachs - not surgical, to be specific. But there is a nifty device that should be in every OR (or at least readily available) called an emergency crichothyrotomy kit. Here is a link that shows you what it looks like:
You insert this through the cricothyroid membrane and use an adaptor to attach a jet ventilator.
A surgical tracheostomy is a procedure performed by a surgeon, not anesthesia. It takes even skilled surgeons several minutes to perform this procedure, so it is literally the last option in an emergent, can't ventilate/intubate scenario.
We've even used a couple 14g. IV catheters for a short-term quick-fix. I doubt this is very effective (no pulse oximeters or anything handy at the time), but it's better than nothing, in a pinch. I don't recommend this in a hospital, but in combat, you roll with what you've got (and save lives doing it).
Oct 23, '05Quote from Athlein1Really? If that is the case this early in your experience, then I would rethink the technique of LMA placement. LMAs are used in the difficult airway algorithm because - correctly placed - they are so reliable.
One of the CRNAs who proctored me has been giving anesthesia for nearly forty years, and he told me this very early on:
Do not tell me that you cannot ventilate. It is YOUR JOB to ventilate the patient, so you better %^&*ing figure it out. Maybe, maybe once or twice in your career will you have a patient that you really cannot ventilate. Then, it's up to you to get oxygen into that patient by whatever means necessary. Until then, don't tell me that it's the LMA, or the habitus of the patient, or some other excuse. Look to yourself first before you go blaming the equipment. And don't tell me that you cannot ventilate. You MUST ventilate.
I cried the whole way home that afternoon. But here I am, just a few weeks from graduation, and I am thankful I learned that tough lesson early on. I know that it will rear its head someday, but I have not been in a "can't intubate, can't ventilate" situation ever since. I haven't had to change LMAs, intubate mid-case (except for the one time that a small case became much bigger when the surgeon ran into an unexpected surgical issue), or chuck the LMA for the tube at induction. If the ventilation is sub-optimal for any reason before the case gets started, the case doesn't start until ventilation is adequate. Seems a no-brainer, but we have all worked with providers who have a questionable LMA and just "hope that it gets us through this case".
That is courting disaster. You MUST ventilate.
My technique was not the problem. Their was a CRNA with me in both instances & yes there are patients in which an LMA does not work as you would like it to. I have heard many CRNAs say that have had some patients they could not get good air exchange and ventilate well with an LMA & so they intubated them. Maybe it was the placement & maybe not, but you have to figure out quickly what's going on & change what your doing. Sometimes that means intubating instead of using the LMA. Earlier I was not talking about the fasttrack & intubating thru it in an emergency. My whole point was that you have to be prepared because each patient is different & there will be a time when the method you have selected will not work-even an LMA is not fullproof.
Oct 24, '05Quote from Patrick M6As one of the above posters stated this may have been initial management of a recognized difficult airway. One management strategy is "awake" blind nasal intubation where the patient is kept breathing spontaneously and sedated with versed/fentanyl or ketamine or a combination, the airway is anesthetized topically with lidocaine, a transtracheal block is sometimes done, and afrin is used to reduce bleeding. The tube is advanced slowly while listening for breathing through the tube, as it reaches the cords the patient will almost suck the tube through. This is a blind technique and I've seen many older (and very experienced) providers are more comfortable with this than fiberoptic. I agree that there is more to this story than told by the lawyers.Does the nasal intubation seem strange to anyone else? We always just "slammed" them in the ER and in the field.