Cuppla thoughts:
1) If anesthesia reported the patient was a difficult intubation it would have been optimal for anesthesia to have been there to reintubate the patient. Preggos are already documented as being a potential airway disaster and in this patient's case, it was made known by anesthesia during the c-section.
2) Micro aspiration is not usually caught with a bronch. Doesn't mean the patient did not aspirate, it just means that it was not observed initially by the dude doing the scoping. The chest film proves this point.
3) Preoxygenating this patient is not going to buy much time. FRC is crap already in this population and she has ARDS. Still should make an attempt though while getting toys and drugs ready. She needs PPV and PEEP to fix her.
4) Being that she recently delivered she remains at high risk for aspiration and I would have treated her as such. RSI with cricoid pressure until ETCO2 verified sort of thing.
5) Pick any induction drug you want. If dosed properly they all give you the same desired response. With a HR in the 130's and elevated BP, ketamine would not have been my first choice. Not giving any midaz with that dose is odd. Dissociative anesthesia without benzos is wrong (unless you are Jerry Garcia). The Wolf is right, etomidate is a nasty drug. Propofol 2mg/kg would get the job done nicely. Quick onset with fewer side effects. Arguing that propofol decreases oxygen supply to tissues is weak in my opinion. It lowers CRMO2 so that is good enough for me.
6) Rocuronium is nice too, but it is a long acting paralytic that takes a while to give you desirable relaxation for intubation. Also, if you cannot place your tube correctly, you have potentially hosed the patient. You guys do have sugammadex over in Europe so at least you have an out if intubation cannot be accomplished. In the United States that drug was burned down in phase III trials and is unavailable. I like succinycholine for these scenarios. Quick onset and unless you have a pseudocholinesterase deficiency, it is gone quickly.
7) I think my 5 year old could still beat me on the Xbox with 50mcgs of fentanyl in her.
8) I don't think things were too bad yet. Take a look at the ASA difficult airway algorithm ASA Difficult Airway Algorithm - Ether - Resources for Anesthesia Research and Education - Stanford University School of Medicine There are many pathways to take before slashing the neck. Video assisted laryngoscopy is not listed in the algorithm yet, but should certainly be considered an option with this patient probably before direct laryngoscopy since anesthesia has already declared this patient difficult to intubate.
Like Wolfman says, it is easy to Monday morning quarterback a case. Don't mean to sound harsh, just wanted to post a few thoughts that crossed my mind upon reading this.
