Had the BE-JESUS scared outta me on call

Just wanted to relate an experience that has changed my perspective forever & installed a very realistic perspective on my evolving level of skills - nothing like a catastophe, or near catastrophe, to instill humility & appreciation for life!

This happened a few weeks ago. I was the senior anesth resident on call & my junior was/is very green. The STAT airway pager goes off at around 1am - I am carrying it, but our call rooms are right next to one another. So, I grab my junior & we trot down to the CVICU.

Pt is elderly post-trauma pt w/ known c-spine injury (questionable whether it is stable) in a c-collar w/ known cardiac disease, recent history of ischemic changes on EKG w/ +cardiac enzymes now with progressing, marked resp distress only maintaining SpO2 (blood oxygen levels) in the mid-80s (normal is > 95%) on 100% oxygen at high-flow. Essentially, this guy is crumping most likely due to evolving congestive heart failure as related to his trauma & cardiac status.

I gathered the troops, assigned specific rolls & cautioned my junior that under different circumstances (no c-spine injury & no c-collar) that this guy would be an easy airway; however, w/ those injuries & his fragile cardiac status, this would need to be clean, smooth & done carefully with strict c-spine precautions to prevent him from falling apart or worsening his extant injuries.

I very gently gave him a staged induction & determined him easy to face-mask ventilate - then gave my paralytic. Oh…neglected to mention he has some degree of renal failure & is greated than 24hrs out from his injuries w/ neurologic sequellae. In English, that means I cannot use Sux for my paralytic due to potentially disastrous outcomes - and Sux is the $hit because it is rapid on & rapid off - only a few minutes. So, I have to go to a different agent that happens to last longer, esp in renal failure because it is approx 25% renally cleared & is simply a longer lasting agent anyhow.

My junior cannot get him intubated. I try - it is one of the worst airways I have yet encountered. I reattempt w/ a Bougie - one of anesth intubation toys that I am very comfortable with - no go! I have the CVICU resident page my staff physician to get her here ASAP. We can still ventilate & oxygenate, but not intubate. My staff tries 2x & misses both. We try to use a fiber optic scope - will NOT work! We begin paging surgery STAT for potential emergency tracheostomy - no answer! Repeatedly page surgery - no answer!

Now, due to multiple intubation attempts, his pharynx is becoming edematous & we are loosing our capacity to ventilate & oxygenate - $hit is really starting to pour onto the fan at high-speed…still no reply from surgery.

So, I insert an intubating LMA - another one of our airway emergency toys - my staff cannot get him intubated still. And, we are continuing to loose our ability to ventilate & oxygenate. Furthermore, he’s now manifesting EKG changes & becoming very hypotensive - dude is going to die if we don’t get an airway NOW!

At that moment, I remembered a trick w/ a normal ETT & the intubating LMA - meanwhile, we are pumping vasoactive agents into this guy to get his BP off of the floor! His SpO2 is in the 60s/70s - very low - and his BPs are 70s/palp w/ pressors - we are loosing fast!

Finally, I succeed in getting him intubated!!! The drop in tension in the room is palpable. His SpO2 gradually begins to improve as does his BP. Just as things are beginning to turn around, the senior surg resident runs up.

Turns out the intern we sent to page surg STAT was paging the wrong person & the operator picked up on all the page entries, interceded & called the surg senior for us.

The gentleman survived w/o damage to heart or knoggin & is actually doing pretty well in light of his traumatic injuries.

This is a war story that I will never, ever forget!

Thanks for sharing your experience, Dave. And congratulations on pulling the gentleman through. I hope he knows how lucky he was to have you there running the team!
And. . . thank goodness for your new toys!

Thank God for perceptive operators!

Thanks for the story Dave!

Wow, that’s an amazing story!

Just curious, since you couldn’t use succinylcholine, what DID you end up using to paralyze him?

Low dose Rocuronium - and it still hung around too long!

Dave, congrats on a successful outcome to a difficult situation.

Holy Crap… what a story! And what a save! Way to go! OMD, keep an eye out for my friend Xan…he’ll be starting his anesthesiology residency at Dartmouth this summer and he’s on the same path as far as preventive medicine. Heckuva guy. Thanks for your post!

Yes, I saw his name on oour match list the Dept released on Th/Fr. My understanding is that Xan will begin w/ the LPM year 1 first & then start clinical anesthesia…same programs, but different order than I am doing. I think the order in which he will take them is a huge improvement over my pathway, which has proven to be unnecessarily challenging. So, he will not work under me until my first year as a staff physician…man, does that have a STRANGE RING to it!

Did you try McGill forcepts? How did you visualize the cords with the unstable neck while using the regular ETT? Just curious.

Was never able to get a better view than the posterior aspects of the VCs - grade III view. I was able to pass an intubating bougie as well as a fiberoptic scope into the trachea. However, he was so anterior, yielding such an acute angle, that the ETT would not make the turn neither on the bougie or the FOscope. First that either I or my staff, veteran of 15+ years, had ever come across such a situation.
Regarding regular ETT & visualization of VCs in a pt w/ suspected neck injury or known unstable neck - seeing the VCs is usually not a problem. I tend to use a MacIntosh (curved) blade except in the case of people in collars or in need of c-spine stabilization when I generally start off with a Miller (straight) blade. Very rarely can I not get a grade I or II view.
Now, just for the edification of the masses, in trauma situations or other situations where c-spine precautions are needed, I was taught a technique early on that will save your @$$. If you hit the esophogus on the first attempt - DO NOT REMOVE IT! Inflate the cuff & grab another ETT. You only have holes at the bottom of the hypopharynx - God forbid you create another one. So, by leaving the “goose” occluded, you not only drastically improve your odds of hitting the right hole the 2nd time around; but you also give yourself some modicum of airway protection from the inevitable emesis from having tubed the goose & subsequent gastric insufflation.

Sort of like an esophageal obterator. Occlude the easy hole, and you can’t miss the other hole.
Cliff Hendren, RRT, RPFT, CPA

Bingo! On the nose Cliff - use it like an obturator.