She needs to be intubated - what is your plan?

[Akulahawk]

While I'm a little late to the game, I'm somewhere along the lines of RRTMedic and VentMonkey on this. I'd rather NOT have to intubate, given the complexity of this case. If there's no question that an intubation MUST occur, I'm probably thinking along the lines of Ketamine with Succs and Versed/Fentanyl to keep the patient down and I'd consider a long duration paralytic if that's absolutely necessary. As far as backup stuff is concerned, has anyone considered the possibility of using a guidewire/reverse Seldinger?

 

[VentMonkey]

As far as backup stuff is concerned, has anyone considered the possibility of using a guidewire/reverse Seldinger?

Nope, but some definitely good food for thought. For the prehospital provider, I am hard pressed to find someone competent enough in this skill though.

 

[StCEMT]

Honestly dont know much about them. I was also keeping my answer within the realm of what I carry, so what I would like is not necessarily what I have.

 

[Carlos Danger]

There really aren't any "right or wrong" ways to manage this or any airway; the only hard and fast rule when it comes to any very difficult airway is to avoid taking away respiratory drive and airway reflexes unless absolutely necessary. I would not attempt to intubate this patient in the field unless it really came down to a "she needs a tube right now or she is going to die" situation. I'm glad that everyone seems to be on the same page with that. So everything we discuss about managing this airway is done with that important caveat in mind.

The first question that I want to answer when I assess an airway is always "can I mask this patient"? If I can mask a patient, then I can attempt intubation safely no matter how difficult it might be to actually pass a tube. Part of the Pierre-Robin sequence is a glossoptosis that can make masking difficult, and this patient looks to me like a potentially very difficult mask. A nasopharyngeal airway may or may not help.

Prone positioning is typically used in sleeping infants and small children whose PR has not yet been corrected. However, any airway obstruction that occurs in the supine position, whether from OSA, a mediastinal mass, an anterior subglottic mass, or a glossoptosis may be relieved by prone positioning. Would you transport a patient with a difficult airway prone? Potentially, sure. There are risks involved obviously, but as long as you have a plan to quickly turn the patient supine if necessary, I think it could be a really appropriate part of your plan of care.

I'm really glad someone mentioned retrograde intubation (@Akulahawk). Assuming the patient is breathing adequately and you do not have flexible fiberoptic available but you do have the drugs and the skill to blunt airway reflexes without abolishing respiratory drive, retrograde is probably the best solution that I can think of. However, if she was breathing adequately I probably wouldn't be messing with her airway in the field in the first place, so it might not be applicable here.

Blind nasotracheal intubation relies heavily on normal anatomy, so it would be hard in this patient. It might be worth a try, especially if it means not paralyzing, but I think it'd be a long shot and remember, we are only doing this because she has to be tubed now. So probably not the best option.

VL may or may not be a better option than DL. I think it depends on which specific device you have and how skilled you are with either approach. I would use whichever you are more experienced and confident with.

The exact approach you use is obviously going to depend on the specific circumstances. There's probably little to be lost by trying an LMA first. Assuming that isn't feasible or doesn't work for whatever reason, I would advocate an approach where we view this airway management operation as a "rapid-sequence cricothyrotomy with a brief pause to attempt intubation", rather than as the normal "rapid-sequence intubation with cric as the backup plan". This means assessing the neck, marking the landmarks, prepare the cric kit, and prepping the neck, while the other operator (hopefully there are two) is going through the normal pre-RSI preparation. Doing everything necessary to make the first attempt the best attempt, someone pushes the drugs and the intubator makes his attempt with the neck cutter assisting. As soon as Sp02 starts to fall or the airway starts to get even a little bloody the laryngoscope blade comes out and the intubator becomes the assistant to the neck-cutter, who does his thing.

 

[ERDoc]

I'd like to hear @Nova1300 , and/ or @ERDoc's input.

I can't see the image.

 

[VentMonkey]

I can't see the image.

It's an adult female patient with a large overbite, bucked-teeth, and zero chin (Pierre-Robin).

 

[StCEMT]

Question then for you Remi. Would you have to down size the LMA due to the airway size? All I have is an igel 4&5 and I wasnt sure how well a 4 would work in this situation, which is why I opted for a different fall back with the given info.

 

[gotbeerz001]

Simpson 4 blade

Sent from my iPhone using Tapatalk

 

[Carlos Danger]

Question then for you Remi. Would you have to down size the LMA due to the airway size? All I have is an igel 4&5 and I wasnt sure how well a 4 would work in this situation, which is why I opted for a different fall back with the given info.

LMA sizes are generally pretty forgiving. I'm not sure if I'd use a 3 or 4 but if a 4 was all I had I'd use it.

 

[Akulahawk]

I'm really glad someone mentioned retrograde intubation (@Akulahawk). Assuming the patient is breathing adequately and you do not have flexible fiberoptic available but you do have the drugs and the skill to blunt airway reflexes without abolishing respiratory drive, retrograde is probably the best solution that I can think of. However, if she was breathing adequately I probably wouldn't be messing with her airway in the field in the first place, so it might not be applicable here.

Blind nasotracheal intubation relies heavily on normal anatomy, so it would be hard in this patient. It might be worth a try, especially if it means not paralyzing, but I think it'd be a long shot and remember, we are only doing this because she has to be tubed now. So probably not the best option.

When I went through P-school, they didn't just present DL as the only way. We were taught VL (it was up and coming even back then!), Digital intubation, Retrograde Intubation, Nasotracheal intubation, Dual-Lumen, EOA/EGTA (among others) and surgical (and needle) cric. There are certain advantages to retrograde intubation. One of them is that it can be used when using blind procedures are your only option. Another is that if you suddenly have to cric your patient, you can just follow the wire through the skin and cricothyroid membrane to the trachea. Yet another is that if you manage to get the guidewire to exit via one of the nares, you can do a retrograde/guidewire NTI.

This patient may also be one of the reasons to use a DSI approach so that you don't end up doing a crash intubation in a patient that's going to be very difficult, airway management-wise.

 

[EpiEMS]

I wonder how hard it'd be to get a decent mask seal on this patient. Could we just occlude the mouth and ventilate through the nose, say, with a pedi mask?

 

[Carlos Danger]

I wonder how hard it'd be to get a decent mask seal on this patient. Could we just occlude the mouth and ventilate through the nose, say, with a pedi mask?

You can do whatever works.

 

[EpiEMS]

You can do whatever works.

Have you tried any technique like that? I've never had the need to try any real expedient BLS measures beyond the standard repertoire...but I always hear of purported good ones...

 

[Carlos Danger]

Have you tried any technique like that? I've never had the need to try any real expedient BLS measures beyond the standard repertoire...but I always hear of purported good ones...

I don't know that I've ever used a small mask over the nose of an adult, but I've certainly done variations of that theme. Old people with no natural teeth and their dentures removed are sometimes more easily ventilated by holding their mouth closed and just ventilating through their nose. Another trick is to place an ETT nasally - not into the trachea, just into the nasopharynx - inflate the cuff, close the mouth and opposite nostril, and ventilate. There's also the dual-lumen ETT adapter attached to bilateral nasal airways trick. I know there are a few others that I'm thinking of now.

Any port in a storm.

 

[StCEMT]

Is retrograde intubation a HEMS/CC skill? I think I remember being taught the concept in medic school, but have never practiced it.

 

[Midazzled]

When I went through P-school, they didn't just present DL as the only way. We were taught VL (it was up and coming even back then!), Digital intubation, Retrograde Intubation, Nasotracheal intubation, Dual-Lumen, EOA/EGTA (among others) and surgical (and needle) cric. There are certain advantages to retrograde intubation.

Where/when did you go to P-school?

 

[Akulahawk]

Where/when did you go to P-school?

I went to ETS in Santa Cruz in 2000. Their program taught skills that went well beyond the usual stuff for California. Some of it was for our own education as some of these skills weren't likely to ever be used by Paramedics in California. Unfortunately they've gone downhill quite severely over the past probably 5 years or so, got bought out by a private college and I think they may have gone out of the EMS training business altogether. At the time I went there, they were regarded as one of the top P schools in the State. It also was quite expensive.

 

[Carlos Danger]

Is retrograde intubation a HEMS/CC skill? I think I remember being taught the concept in medic school, but have never practiced it.

I didn't learn it in paramedic school, but I picked it up when I was flying.

 

[RRTMedic]

Retrograde does seem to be the ideal here. Kinda disappointed I didn't think of that...

Again, I'm pretty big advocate for NIV BiPAP here. If at all possible, keep the patient on some ketamine and run bipap. Keeps the airway open and provides Ventilation.

Then again, mask seal would be difficult. Nasal bipap with chin straps might be your best option with an NPA adjunct.

 

[Tigger]

Step 1: Can I mask the patient? If that isn't happening, we'll probably be stuck to moving pretty quickly to a surgical crich, I am not eve sure a King tube could be inserted that was an adequate size. I'd still try, But if we have a cannot ventilate type situation, trying to make a King pass is probably not a good use of time.

If we can get some semblance of seal, I'd use 2mg/kg of Ketamine and go in with the McGrath with the patient hopefully sitting at 30-45 degress, though I am betting it would be difficult to find room for the blade and the tube. I would still opt for video on the first go around and have an assistant hold the patient's cheek as wide as possible to help pass the tube. Maybe just use the bougie (not pre loaded) instead. Once (if) passed, I think I would use a long term paralytic as an added safety net to prevent losing it, along with fent and versed.