How would you manage this airway?

Specialties CRNA

Published

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

Specializes in Anesthesia.

Straight to trach, IMHO.

Z

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

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mike - because of the injuries - including the fx/unstable mandible - i would not mess around and cric the patient...

as far as meds - maybe scopalamine andi f i absolutely had to sux or roc ... but if grey matter is hanging out...i would think recall will be my last problem..

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Specializes in I know stuff ;).

Hey again :)

Tensema - Yer crackin me up. I totally agree this fellow is (was) an organ donor but i dont have the power to make that decision!

As for the case here is the result:

This is a case I use to train flight RNs/EMT-Ps in airway management, yes it actually happened about 6 years ago and i was the person to respond.

Here would be the most correct intervention based on the situation in the field, you may see it differently based on the same pt being rolled into the trauma room:

- Insert OPA begin BVM only to find the sat stays that low. OPA is important here if you can pry the jaw open enought to get it in (which we could) due to the risk of an altered person choaking on their tounge (seen it twice now). That may have well explained the low sat... it didnt.

- Suction didnt do a damn thing. Blood filled as fast as it was removed so this is a blind procedure by definition.

- The inability to BVM this patient effectively had alot to do with the fact that his lower jaw was Fx'd and there were skin tears under his mandible. Without the ability to create a good seal, paralytics are absolutely contraindicated in this case. IE: pt breathing at rate of 6 with sats in 70 previous to succs, cant BVM (Bag Valve Mask BTW) = pt not breathing at all and dead if tube isnt successful. Its the one true contraindication for paralytics.

- So now there is a patient with a bloody airway, jaw fx and tears preventing effective ventilation with bag, mild degree of trismus (after all how much can u have with a fx jaw), Sats 78%.

- This patients mouth could not be opened enough to accomidate our combitube or ILMA. No paralytics could be given and etomidate did nothing to change the trismus.

- The patient was surgically cric'd. We train to do it by hand with a #10 scalpel. Havent used the devices out there.

OK

so some points for discussion:

Yoga mentioned nasal intubation. One of the contrindications of nasal intubations is possible basilar skull fx. While some will look for racoons eyes and battle signs (indicitive of basilar skull fx) they are late signs and never seen acutely but in dead people. However, i want to also say that yoga is very right when she says "never say never". The chances of having a basilar skull fx large enough to accomodate ANY adult ETT is negligible. Based on a lecutre given by a few local attending neuro-surgeons, it has never happened and will never happen to living people. So could you do it? Yes. Would it be defendable, maybe. Thats where its contraindicated.

Now, it is definitly possible to get an NG tube in the brain via a small basilar skull fx or cribriform plate fractures. I have CT scans and Xrays of this. So thats absolutely contraindicated.

The reason a nasal was not tried was pure time. It is faster for me to cric a patient than listen for a nasal on a bloody airway, much harder to hear even with a BAAM device.

Pt became an organ donor.

Now before anyone starts crying that im "tooting my own horn" like the last time i presented something here, let me quantify this. I am an educator, I love to teach. The truth is that there are few (if any) CRNAs (or MDAs for that matter) who will see the types of airways in the condition I do. Afterall, i bring them intubated. This is one place where i can add to the groups knowledge base for the time when you see one this bad.

Hope it was helpful.

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Specializes in Emergency room, med/surg, UR/CSR.
Hey again :)

Tensema - Yer crackin me up. I totally agree this fellow is (was) an organ donor but i dont have the power to make that decision!

As for the case here is the result:

This is a case I use to train flight RNs/EMT-Ps in airway management, yes it actually happened about 6 years ago and i was the person to respond.

Here would be the most correct intervention based on the situation in the field, you may see it differently based on the same pt being rolled into the trauma room:

- Insert OPA begin BVM only to find the sat stays that low. OPA is important here if you can pry the jaw open enought to get it in (which we could) due to the risk of an altered person choaking on their tounge (seen it twice now). That may have well explained the low sat... it didnt.

- Suction didnt do a damn thing. Blood filled as fast as it was removed so this is a blind procedure by definition.

- The inability to BVM this patient effectively had alot to do with the fact that his lower jaw was Fx'd and there were skin tears under his mandible. Without the ability to create a good seal, paralytics are absolutely contraindicated in this case. IE: pt breathing at rate of 6 with sats in 70 previous to succs, cant BVM (Bag Valve Mask BTW) = pt not breathing at all and dead if tube isnt successful. Its the one true contraindication for paralytics.

- So now there is a patient with a bloody airway, jaw fx and tears preventing effective ventilation with bag, mild degree of trismus (after all how much can u have with a fx jaw), Sats 78%.

- This patients mouth could not be opened enough to accomidate our combitube or ILMA. No paralytics could be given and etomidate did nothing to change the trismus.

- The patient was surgically cric'd. We train to do it by hand with a #10 scalpel. Havent used the devices out there.

OK

so some points for discussion:

Yoga mentioned nasal intubation. One of the contrindications of nasal intubations is possible basilar skull fx. While some will look for racoons eyes and battle signs (indicitive of basilar skull fx) they are late signs and never seen acutely but in dead people. However, i want to also say that yoga is very right when she says "never say never". The chances of having a basilar skull fx large enough to accomodate ANY adult ETT is negligible. Based on a lecutre given by a few local attending neuro-surgeons, it has never happened and will never happen to living people. So could you do it? Yes. Would it be defendable, maybe. Thats where its contraindicated.

Now, it is definitly possible to get an NG tube in the brain via a small basilar skull fx or cribriform plate fractures. I have CT scans and Xrays of this. So thats absolutely contraindicated.

The reason a nasal was not tried was pure time. It is faster for me to cric a patient than listen for a nasal on a bloody airway, much harder to hear even with a BAAM device.

Pt became an organ donor.

Now before anyone starts crying that im "tooting my own horn" like the last time i presented something here, let me quantify this. I am an educator, I love to teach. The truth is that there are few (if any) CRNAs (or MDAs for that matter) who will see the types of airways in the condition I do. Afterall, i bring them intubated. This is one place where i can add to the groups knowledge base for the time when you see one this bad.

Hope it was helpful.

Thanks, that was a good inservice. I'm glad the patient became an organ donor too. I was thinking throughout the whole thread that the first thing I would have thought of when I was a medic would have been to do a cric due to patient needing the airway now. If the patient was already coded, would you have attempted resuscitation or just declared him dead? Just curious what you all do in your neck of the woods. In our area, if the patient was already dead, we would have called for the coroner instead of trying to revive a dead person.

Pam

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Specializes in I know stuff ;).

Hey TM

Yup, i would have called him directly on the field.

Glad you enjoyed the review :)

If people like this sortof thing i can do many more. I currently present cases nationally for flight teams and on a website for flight teams. I usually use pics and such but its not an option on this board.

Thanks, that was a good inservice. I'm glad the patient became an organ donor too. I was thinking throughout the whole thread that the first thing I would have thought of when I was a medic would have been to do a cric due to patient needing the airway now. If the patient was already coded, would you have attempted resuscitation or just declared him dead? Just curious what you all do in your neck of the woods. In our area, if the patient was already dead, we would have called for the coroner instead of trying to revive a dead person.

Pam

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exposed gray matter and blood in the lungs does not make for a good donor (except for bone/cornea, and you don't have to keep them intubated for that).

the force of impact to reveal gray matter is not compatible with life, and therefore you are just keeping a brainstem alive.

etomidate is useless for many reasons

your only choice is a cric... but what a waste of time in the field. I would just bag-valve mask and transport to the hospital and hopefully the pt would expire en-route...

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Specializes in I know stuff ;).

Hey T

While I agree with you, there is little choice but to intervene. Not managing this airway in some way with sats in the 70% (with BVM) would be negligent on my part even if i believe it is futile.

As for the donor, from what i was told his kidneys, liver, cornea, connective tissue and skin were all viable (possibly more i cant remember what else was said). If the patient was not cric'd (which takes me less than 3 minutes including prep) his sats would have not come up at all probably expiditing his inevidible death.

I know why etomidate didnt do anything to trismus, but it is always worth it to assume the patient may be mentating and sedate for comfort. In fact, its standard of care.

As for head injuries being incompatible with life, this isnt always the case. I have seen full GSW to the head walk out of the hospital grey matter on either side. Also had many trauma patients with severe head injury including depressed skull fx with grey matter oozing out live to discharge. Its not as black and white as you seem to imply.

While I understand your cynicism in this case and i often share it, it is not for me or you for that matter, to decide not to intervene. This is a decision soley for the parents or proxy. Even if his death helped one person it helps to ease the suffering of the family. I have seen it first hand.

exposed gray matter and blood in the lungs does not make for a good donor (except for bone/cornea, and you don't have to keep them intubated for that).

the force of impact to reveal gray matter is not compatible with life, and therefore you are just keeping a brainstem alive.

etomidate is useless for many reasons

your only choice is a cric... but what a waste of time in the field. I would just bag-valve mask and transport to the hospital and hopefully the pt would expire en-route...

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While I understand your cynicism in this case and i often share it, it is not for me or you for that matter, to decide to euthanize. This is a decision soley for the parents or proxy. Even if his death helped one person it helps to ease the suffering of the family. I have seen it first hand.

Euthanasia? By not intervening? Maybe negiligent, but it probably wouldn't hold up, in that situation. Certainly not euthanizing, though.

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Specializes in I know stuff ;).

Good point lemur

I suppose it isnt active but it is contributing to the death be choice. Still not acceptable in anycase! I edited the post to make more sense.

Euthanasia? By not intervening? Maybe negiligent, but it probably wouldn't hold up, in that situation. Certainly not euthanizing, though.
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in the OR cric...

in the field, have someone do a chest compression and intubate the bubble.

d

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Specializes in I know stuff ;).

heh

It isnt that simple when a patient has trismus. Secondly, the ground medics had made an attempt twice before arrival. The most correct answer here is cric due to the circumstances. The patient was not pulseless with sats in the 70's, spending the time to do chest compressions, force open the jaw to intubate and make more attempts is really contraindicated. The field is a whole different place ;)

in the OR cric...

in the field, have someone do a chest compression and intubate the bubble.

d

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Mike,

Excellent post, i hope you will do more like these.

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