She needs to be intubated - what is your plan?

[Carlos Danger]

What drugs and technique?

Go.

 

[VentMonkey]

Pierre-Robin?

All equipment set up--->OPA(s), BVM,suction, etc. at the ready. For the sake of argument, I am saying she's awake, and we will be inducing her via RSI. If she can, ask to stick her tongue out though clearly the "3-3-2 rule" here dictates some difficulty to say the least. I don't carry Ketamine yet so...

Etomidate--->Succynlcholine--->ETI (sit her at a ~30-45 degree angle with a pillow behind her head). Assuming all went well on the first attempt (guessing this isn't the case), proceed with post RSI care---> Fentanyl/ Versed to be kept comfortable.

Another part of preparing would be having at least one step down on a blade (I would probably start with a Mac #3, and move to a Miller #2 if the first attempt was unsuccessful). I go Kiwi-grip bougie as well, third attempt at ETI is VL. I would also have a proper sized King LT at the ready, and needle cric (no surgical cric here either sadly) not to far away.

Thee biggest thing for preparing an induction with a patient like this IMO is the "P" that= "P"reparation. Checking all my equipment is ready and where I can reach it is imperative. Another thing that would be nice is an even more advanced airway provider with me, though this isn't the case in my setting.

Another pointer to be made, as it has before, as long as this patient can be properly oxygenated AND ventilated this isn't a failed airway; not a bad idea to utilize a peds mask/BVM with this young lady as well.

I await the input of my peers...

 

[RRTMedic]

Dang... well, my first instinct is to avoid intubation at all costs. NIV, BVM, whatever works till we get to the hospital.

Intubation needed, no questions asked? Video initially with bougie insertion. Next step would be miller blade (due to small oral opening) with bougie insertion. Failed airway devices? Geez... BIAD... cric if SpO2 can't stay above 92%.

Medications? Ketamine for sure due to a less chance of respiratory depression. I would be really hesitant to paralyze but if it comes to it, succs and nothing else.

Above all: avoid intubation. This is the job for an anesthesiologist. Basic airway manuveirs with optimal positioning and two person jaw technique with BVM and adjunct.

 

[Carlos Danger]

Good stuff so far. I'll save my comments until we have a few more responses.

 

[RRTMedic]

Thinking about the direct laryngoscopy with this patient scares me due to the over bite. I probably would stick with a glidescope or airtraq for her if available.

 

[VentMonkey]

Dang... well, my first instinct is to avoid intubation at all costs. NIV, BVM, whatever works till we get to the hospital.

Intubation needed, no questions asked? Video initially with bougie insertion. Next step would be miller blade (due to small oral opening) with bougie insertion. Failed airway devices? Geez... BIAD... cric if SpO2 can't stay above 92%.

Medications? Ketamine for sure due to a less chance of respiratory depression. I would be really hesitant to paralyze but if it comes to it, succs and nothing else.

Above all: avoid intubation. This is the job for an anesthesiologist. Basic airway manuveirs with optimal positioning and two person jaw technique with BVM and adjunct.

You're no fun! (kidding) In all seriousness this is a great "teaser" to see what all people's different approaches would be in the prehospital realm.

I like it, I mean how many paramedics do you know that whine about why they still need to intubate?

To those paramedics specifically I say "let's hear your thoughts and reasoning as well, i.e., your critical-decision/ thinking/ reasoning".

After all, failing to prepare is preparing to fail.

 

[RRTMedic]

You're no fun! (kidding) In all seriousness this is a great "teaser" to see what all people's different approaches would be in the prehospital realm.

I like it, I mean how many paramedics do you know that whine about why they still need to intubate?

To those paramedics specifically I say "let's hear your thoughts and reasoning as well, i.e., your critical-decision/ thinking/ reasoning".

After all, failing to prepare is preparing to fail.

You got that right. This chick is all about planning, as every RSI should be. There better be a really good reason to intubate her, and I'm sure any anesthesiologist would consider alternatives if possible.

 

[RRTMedic]

no surgical cric here either sadly)

Are you referring to your scope of practice at this time or the patient's condition? I would feel much better about a surgical airway (even if it may accidentally be a trach) than a need cric. I feel that the space you're working with would make a surgical cric less than ideal, not considering the need for a better airway than a 14 gauge catheter.

 

[EpiEMS]

How about nasotracheal intubation? I don't know anybody who has that in scope, but I would imagine medical control may be able to help...

Video laryngoscopy would likely assist on this one.

 

[VentMonkey]

Are you referring to your scope of practice at this time or the patient's condition? I would feel much better about a surgical airway (even if it may accidentally be a trach) than a need cric. I feel that the space you're working with would make a surgical cric less than ideal, not considering the need for a better airway than a 14 gauge catheter.

A bougie-introduced surgical airway is certainly something I would look forward to performing on this patient, though that vs. a 14-gauge needle as an option goes without saying.

So, to answer your question, I was referring to both. One of the EmCrit podcasts on surgical crics talks about promoting and identifying your landmarks AHEAD OF TIME on patients where this may be potentiated, e.g., difficult airways such as hers.

I agree this isn't an "ideal prehospital ETI candidate", but nonetheless having all of the tools in your toolkit can only help and I think that cannot be emphasized enough.

 

[VentMonkey]

How about nasotracheal intubation? I don't know anybody who has that in scope, but I would imagine medical control may be able to help...

Video laryngoscopy would likely assist on this one.

Definitely worth considering, however, with her particular anatomy and medical condition you're looking at a smaller cuffed tube.

Also, understand this can also be a brutal procedure not without risk. Great thinking, though.

P.S. I miss having that skill set in my scope.

 

[StCEMT]

There is no image showing, is this someone with Pierre Robin?

 

[VentMonkey]

There is no image showing, is this someone with Pierre Robin?

Yes.

 

[StCEMT]

Ok, think I managed to figure out enough about the patient to give it a go (I believe this is an adult? Slightly different rules to play by if so). Feel free to educate me from here folks.

I have heard mention of putting these patients prone with respiratory problems, but its been a while and I honestly don't remember much about it, I can see the benefit with the goofy airway though. Since some of our airway management requires consultation, I'd be calling a doc for advice and orders since Ketamine falls under consultation. I would probably have everything laid out in this case. Needle cric set up, did have one instructor talk about using needle before surgical once, so that's where that thought comes from. Then the scalpel, an ET tube cut down (I can't see the picture, so unsure what size), a bougie to guide in the ET tube, and something to secure it with. Make sure I have already checked for landmarks while setting up so I at least know what I am working with. I am gonna guess I would probably have a #3 miller since I think it would fit better with their airway size (personal preference too) and whatever appropriate size ET tube and have it set up with the kiwi grip. Also probably something like a blanket rolled up, if I am picturing the anatomy right, something to lift the head more would still be a benefit in this folks.

Nasal intubation is an option for me, so that is something I'd be thinking pretty serious about, I feel like this might be one of the rare instances I would actually prefer it. If not, ask about Ketamine which we are told in this case to give 2mg/kg, otherwise etomidate at 0.3mg/kg. Position the head with blanket or pillow, elevate the stretcher some so I can work comfortably and not be hunched over trying to get a good view before giving meds. From there, hopefully I would at least have some visible landmarks to guide the bougie with. If it sticks, great, if not I would probably go to needle cric to get some ventilation while I get ready for a surgical cric. From there, basically Scott Weingarts cric method. Cut, finger, bougie, tube. Follow up with sedation any time after tube, in my case we are told 2.5-5mg versed.

That's probably the gist of my plans so far, because the only other thing I would be thinking is "oh ****". Had a kid with some respiratory issues not long ago that I am fairly certain had this despite parents not knowing an official diagnosis, and that little dude had me worried for a couple minutes.

 

[VentMonkey]

Ok, think I managed to figure out enough about the patient to give it a go (I believe this is an adult? Slightly different rules to play by if so). Feel free to educate me from here folks. Nasal intubation is an option for me, so that is something I'd be thinking pretty serious about, I feel like this might be one of the rare instances I would actually prefer it. Had a kid with some respiratory issues not long ago that I am fairly certain had this despite parents not knowing an official diagnosis, and that little dude had me worried for a couple minutes.

It is an adult. Something else to consider re: NTI, these patients may often have cleft palates further causing damage, and/ or decreasing the likelihood of a successful NTI.

I haven't heard of the prone position for them and doubt I could use it in the field, interesting though.

Basic care (OPA+upright fowlers) is usually sufficient with basic prehospital airway manuevers in these little guys/ gals. Obviously closely monitoring their airway/ SPO2 for any changes as well; these are non-invasive measures.

 

[StCEMT]

I forgot about the palate, good point. Although how much surgery have they had usually by adulthood to fix that?

I dont know what my option is either with that, but something I would keep in mind.

Thats how we managed that baby. He had a NPA that stayed in at home. We put a blanket under the rear of the car seat to lean it forward more, 6fr to suction the NPA out, and an NRB to give blow by O2.

 

[VentMonkey]

I forgot about the palate, good point. Although how much surgery have they had usually by adulthood to fix that?

I dont know what my option is either with that, but something I would keep in mind.

Thats how we managed that baby. He had a NPA that stayed in at home. We put a blanket under the rear of the car seat to lean it forward more, 6fr to suction the NPA out, and an NRB to give blow by O2.

I don't want to take away too much from @Remi's thread, and will wait for his reply, but you and @EpiEMS actually aren't far off in your airway choice.

 

[Handsome Robb]

Ketamine for sedation and NTI are my knee jerk reaction. Definitely would not attempt DL on her.

Ketamine would be my first choice followed by etomidate. My go to would be roc as its all we carry but I might consider sux because of the short half life even though it's not a super sound thought process that it will wear off faster if we absolutely need it to.

Definitely a bougie pre-loaded with a surgical crich kit close by as well as an iGel. Might have to go a size down on the iGel.


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[SpecialK]

I do not have the skill or experience to intubate this patient. I doubt any ambulance personnel or many ED medical staff would either.

My plan would be to use an LMA if I could, or if she had any oxygenation problem and really needed something more then try disassociating her with some fentanyl and ketamine and using a good sealing bag mask with PEEP to improve her oxygenation.

If she actually needed a definitive physical airway and didn't just have an oxygenation problem I'd perform a surgical cricothyrotomy. I know that might sound brash of me but honestly the only way I know for sure I can get a tube into her trachea is to cut her throat.

 

[VentMonkey]

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