King airway in obese patients...

[Akulahawk]

I don't know a whole lot about retrograde intubation but my best guess is it wouldn't have been an option here because of the total lack of neck on this patient (think Jabba the Hutt).

That makes sense... In that situation, it makes sense that there's just a LOT of tissue to go through just to find the cricothyroid membrane, and if you can't find that, I sense much :censored::censored: coming from somewhere or someone.

 

[paradoxicalmotion]

Given the experiences I've had with this particular ER and their airway management capabilities in the past, I'd seriously doubt they would even have the necessary equipment (granted, like I said, I'm not super familiar with the procedure and I don't know what it requires) or even the know-how to do it.

 

[triemal04]

Of of curiosity, what would you have done during your 1 hour transport if you stopped being able to effectively ventilate the patient with a BVM?

Would you have attempted to intubate the patient? With or without paralytics (if you have that option?)

Would you have then placed a King airway?

Something else?

I'm sure you had a plan in place, I'd just like to know what it was.

I don't know what the capabilities of that hospital are, but personally I would have refused to leave until the airway was secured with SOMETHING. King, LMA, igel, ET tube, something would be in place before I left. If that meant that the ER doctor admitted defeat and called anesthesia, a RT, ICU doctor or someone else then so be it. But if he felt that her airway was unstable enough that it needed to be secured in the ER with all their available resources, then it damn sure needed to be done before you left that setting.

 

[paradoxicalmotion]

The capabilities of the hospital are minimal. He was the only physician there at the time. They do not have any RTs on staff, and I believe their anesthesiologist is shared between a few of the area hospitals - I did ask the nurse if anyone knew how to page/get ahold of him, and no one knew.

Like I said before, my service has had issues in the past with this hospital and their airway management - if it had been any other hospital I would have refused to transport until the airway was secure. In this case had I been any less comfortable with managing the airway BLS, I would have insisted.

I did have a backup plan: At my request the nurse drew up induction doses of etomidate and succ's (my service does have RSI capability but we don't carry nearly enough of either for an induction dose of a patient that size), which I had sitting on the counter, right next to a King airway out of the package, next to an open tube of lube, next to a laryngoscope and blade. If I lost her airway enroute my plan was to RSI her, try the King, and if necessary, use the laryngoscope to help seat it properly. I know some will probably argue I should at least try for an ET intubation before going to a King, but with her SpO2 rollercoastering on me, I figured the less playing around and looking for cords the better at this point.

 

[triemal04]

Well done. Sounds like you did what you could before leaving and had a well thought through plan and had it as prepared and ready to go as possible. Can't ask for more than that. And if anyone complains about you not wanting to attempt ETI in this situation...I wouldn't listen.

I would think about a couple of things, and if this type of situation really is an ongoing issue, then it really needs to be looked into, and resolved ASAP at a higher level than you.

What if the King didn't work? I'm guessing you would have tried ETI at that point, but if that also failed, you are now in a "can't intubate can't ventilate" scenario where your backup airway has also failed. You've allready recognized that this isn't someone who's neck you want to be cutting...so...what would you do? I would rather be faced with that situation in the ER before leaving while the patient is still under the care of the MD, or at least know before leaving that the BVM is the only option.

Keep in mind that this is a 500+lb patient who has just had multiple traumatic attempts at securing an airway. What if her tissue starts to swell? What may have been an airway that could be ventilated by BVM (with difficulty), is now something very different.

What I'm getting at is insisting that the king at least be attempted before leaving or another practitioner be brought in, especially with that long of a transport. It sounds like this is not a hospital that would stand behind you if something went wrong after you left, so ensuring that things were as stable as possible before leaving, beyond being best for the patient, is best for YOU.

I don't know what resources are available, but it is also worth considering if bringing in another outside resource would be viable. In this particular case with the limited info you shared the patient doesn't sound extremely time sensitive, so waiting for more hands could be worth it.

Really, the head of your department and medical director need to be involved, if they aren't allready. If this really is a recurring problem then you and your service are heading for a disaster. Even if the hospital or physician group refuses to change things, having a documented attempt at change when something goes badly will be extremely beneficial.

And it is "when," not "if."

 

[truetiger]

RSI'ing this patient once she starts crashing is going to be a disaster. You noted that you were having to work to keep her in the high 80's, low 90's. Once a patient's pulse ox drops below 90, its going to start dropping exponentially faster. You have think, she has no residual volume due to her size. Now you take a sick, obese patient and you have a real problem if she goes apneic on you. You'll be playing catch up on the side of the road with no support.

 

[Handsome Robb]

So this might be completely impossible and I only have a basic knowledge of retrograde intubations and with what you've described about he facility I highly doubt it even was a thought but could it be done under ultrasound guidance?

Again, I have a limited knowledge of retrograde intubations and ultrasound capabilities.

I'm with others I'd have been real upset about taking this patient without an airway in place. Sounds like they're gonna be too big for a tracheostomy. I know that's jumping way down the algorithm but if you can't protect her airway or she dies from aspiration acquired pneumonia who cares about here hepatic encephalopathy?

Also, too add to the LMA vs ETI in ORs during my paramedic clinicals almost every single procedure was done with an LMA. Pretty disappointing for me from a student standpoint. I still learned a ton about airway management but we don't use LMAs.

 

[Carlos Danger]

RSI is not the answer in a patient like this, unless she was truly in extremis. I do not blame the doctor for not wanting to use NMB's. This is a patient who needs to be intubated by anesthesia or ENT, quite possibly using an awake fiberoptic technique.

If the doc absolutely could not secure the airway and really had no one to call, then the patient should have stayed in the ED - on CPAP or BIPAP if needed - until someone came in the next morning who could do it. Both the transporting crew and the patient were put in a really bad situation because of "this patient needs to get out of here-itis".

Someone mentioned retrograde. That may have been a good option IF you could easily palpate the CTM, but in a 500+ patient I imagine they may not have been able to, which means they also couldn't do a cric, which is another reason why NMB's were a bad idea.

 

[paradoxicalmotion]

Halothane, quick question about using fiberoptics - The only times I've seen it performed have been in very busy, metro ED's and it was the EM residents performing it, rather than anesthesia. I myself don't know very much about it. Is this a procedure I can expect a rural ER physician to be trained in, and beyond that will they even have the equipment necessary?

 

[Av8or007]

This is a tough one. If they weren't unconscious I would have said to do them awake with topical anesthesia +/- moderate ketamine sedation.

Since the pt is unconscious, this presents an issue since an awake intubation is no longer possible. I would say (not that i know anything about this so take with a mole of salt) that you would first want to try preoxygenation to get the spo2 up to a safe level.

It may be possible to preoxygenate on BiPap if you are at the bedside at all times but use caution.

 

[Av8or007]

It may be possible to preoxygenate on BiPap if you are at the bedside at all times but use caution re the risk of aspiration and recognition of apnea.

If the patient requires manual/mechanical ventilation then use a peep valve - failure to oxygenate at high fio2's is often due to shunt.

If/when spo2 is at a safe level, apply an nc @15 for ApOx. Position the patient, ramping as required.

As for intubation im not sure of the best approach, but you do need first pass success in these obese pts.

One could use etomidate or even ketamine (can we get some vitals to help select meds?). Ketamine will preserve whatever little airway reflexes the patient has and they will keep breathing.

One suggestion would be to attempt placement of a king/lma after ONE attempt at ETI.
If this SGA can be successfully placed, then either ventilate through that or use a bougie to exchange the SGA for an et tube once the patient has been reoxygenated. (this can be done on lma, not sure about king).

 

[Handsome Robb]

I have another thought. While she isn't awake she's still spontaneously breathing, no? Is a NTI reasonable. I'm guessing no with the atypical anatomy but I still argue that something needs to be done.

Also, av8 brings up a HUGE point. I think a bougie and video laryngoscopy or fiber optics would be a good solution for an airway attempt. I also agree with a bougie exchange which I believe av8 mentioned as well. If you can get the king seated well enough and get we bougie in that's a definite possibility with laryngoscopy assistance.

 

[Carlos Danger]

In the real world, the best option is probably VL done with ketamine or dexmedetomidine and aerosolized lidocaine, and a bougie close at hand. Positioning is KEY with very large patients. If that doesn't work, then you can hopefully use CPAP (if needed) to bring their sats back up maintain until you figure out a retrograde or fiberoptic approach. Anything you do is very risky in a patient this large, though, especially when they are already sick and therefore working on what little reserve they have. You'd really have to be prepared for rapid decompensation and be prepared to cric quickly (assuming you can locate the CTM, of course).

Halothane, quick question about using fiberoptics - The only times I've seen it performed have been in very busy, metro ED's and it was the EM residents performing it, rather than anesthesia. I myself don't know very much about it.

You don't see these done much in the ED in general, because it isn't really an emergency procedure.

When it is, I've never seen or heard of it being done by anyone other than anesthesia, ENT, or pulmonology. In the ED it is most commonly anesthesia, IME, but I'm sure there are places where it is different. I don't know if it is something that most EM residents are trained in.

A big part of an awake fiberoptic intubation isn't just using the fiberoptic scope to place the tube; it's the anesthesia that goes along with it. The patient needs to stay breathing and cooperative, yet be able accept an ET tube. Or they need their airway reflexes blocked with local nerve blocks. So for that reason probably more than any other, these generally end up being anesthesia's thing.

Is this a procedure I can expect a rural ER physician to be trained in, and beyond that will they even have the equipment necessary?

Most likely not. I'm sure there are some out there somewhere who are, but they'd probably be a small minority.

It's important to keep in mind that it's a relatively small percentage of patients in whom fiberoptic intubation is indicated. Again, it's not really an emergency procedure, though it could be if the operator is really good at it.

 

[paradoxicalmotion]

At one point during his laryngosocopy attempts I did suggest ketamine, to which he replied that he didn't believe they have it. I offered ketamine out of my narc pouch and he refused, stating the etomidate was enough.

As far as positioning goes, while he was off dealing with another patient I was directing set up for everything, and with the help of a second crew, the x-ray tech, and the lab tech, we were able to ramp up the patient so the ear was in line with the sternum.