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16. Difficult Airway and OMG, There’s Blood Everywhere: Navigating the Difficult Airway
Keywords
Difficult intubationDirect laryngoscopyVideo laryngoscopyEndotracheal introducerCricothyrotomyLEMONS lawCase
A 42-year-old male presents to the emergency department with vomiting. The patient’s family comes to the front desk and explains that the patient cannot get out of the car and has been vomiting blood. Security and nursing staff extricate the patient to a wheelchair and deliver him to a critical care bay while calling for physician help. You arrive to see the patient slumped in the wheelchair, dark blood pooling in his mouth and covering his shirt. The family tells you that he was just admitted for rectal bleeding, and he had left the hospital against medical advice earlier that morning. His baseline mental status is normal, but he is currently only responsive to painful stimulation. The patient is moved to the critical care bed and initial assessment is started.
Pertinent Physical Exam
Except as noted below, the findings of the complete physical exam are within normal limits.
Blood pressure 99/40, pulse 143, temperature 97 °F (36.1 °C), temperature source Oral, respiratory rate 28, height 1.803 m (5′ 11″), SpO2 84%.
Head, Eyes, Ears, Nose Throat: Atraumatic. The patient is actively vomiting. Trachea is midline. There is no appreciated oral edema.
Cardiovascular: Normal S1, S2. Tachycardic. Cool extremities, capillary refill 4 seconds.
Abdomen: Distended, +fluid wave.
Skin: Slightly jaundice, spider hemangiomas present on chest, and palmer erythema.
Neuro: The patient is not following commands, GCS 9 (E2V2M5). Does move all extremities spontaneously. On initial presentation, the patient is more responsive, but during the evaluation, his mental status decreases to GCS 6 (E1V1M4).
Past Medical History
Alcoholic cirrhosis with prior variceal bleeding.
Social History
Current every day smoker, continues to drink alcohol.
Family History
No pertinent past family history.
Pertinent Test Results
Lab Results | |||
|---|---|---|---|
Test | Results | Units | Normal Range |
WBC | 14.1 | K/μL | 3.8–11.0 103 / mm3 |
HGb | 5.5 | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Platelets | 135 | K/μL | 140–450 K/μL |
Creatinine | 1.4 | mg/dL | 0.6–1.5 mg/dL |
Potassium | >10 | mEq/L | 3.5–5.5 mEq/L |
Lactate | 6.1 | mmol/L | <2.0 |
INR | 1.4 | – | ≤1.1 |
Glucose | 110 | mg/dL | 65–99 mg/dL |
pH | 7.11 | – | 7.35–7.45 |
Emergency Department Management
The patient was critically ill requiring immediate intervention. He was placed on a monitor, two large-bore peripheral IVs were established, and blood pressure recycled frequently. A definitive airway, given his altered mental status and copious hematemesis (vomiting blood), was an initial priority. He was identified to have a difficult airway given the amount of blood in his oropharynx, high risk of aspiration, and risk for decompensation during intubation given his profound presumed hemorrhagic shock. The patient was immediately placed on a non-rebreather face mask, oxygen turned to “flush,” and had a nasal cannula placed with oxygen turned to 15 liters per minute. Team members attempted to suction the airway while others prepared for intubation. The team elected for low-dose etomidate sedation without paralysis given the predicted difficult airway. After induction, the first attempt was performed with direct laryngoscopy with a Macintosh blade. The resident was unable to visualize the vocal cords due to the amount of blood in the airway. A large-bore suction catheter was placed in the posterior oropharynx and left there during the attending physician’s second attempt. With the assistance of a bougie device, the patient was successfully intubated with a 7.0 endotracheal tube. The balloon was inflated, and end tidal CO2 was confirmed with a color-change device. The team continued resuscitation efforts initially with O negative trauma blood and subsequent massive transfusion protocol with O positive blood.
Updates on Emergency Department Course
The patient continued to have profound blood from oral gastric tube. A Blakemore tube was inserted in attempt to tamponade the presumed bleeding esophageal varices. The gastroenterology team was consulted, which recommended against immediate upper endoscopy because the patient was critically unstable. Gastroenterology instead recommended ongoing aggressive resuscitation in the intensive care unit. Interventional radiology was not available to discuss transjugular intrahepatic portosystemic shunt (TIPS) placement.
Learning Points
Priming Questions
- 1.
How do you identify the potentially difficult airway?
- 2.
What special preparations are necessary for the anticipated difficult airway?
- 3.
What techniques will improve chances of success during intubation?
Introduction/Background
- 1.
While managing a patient’s airway is a routine aspect of emergency medicine, the anticipated difficult airway often unnerves even the most seasoned emergency physician. Fortunately, these events are rare [1, 2], but the provider must always be prepared for the myriad of airway challenges about to roll in the front door.
- 2.
Applying a step-wise checklist to every airway approached, including the crashing patient with a difficult airway, will provide a sense of security.
- 3.
Even an anticipated “easy” airway can have surprise difficulties. It is best to always prepare for the worst and have a stepwise approach to various backup options, including surgical airway options for the “can’t intubate, can’t oxygenate” scenario.
- 4.
Brown and Walls have developed approaches for evaluating difficult airways [3]. The first question is whether the patient is crashing—cardiopulmonary arrest, respiratory arrest, and agonal respirations. If not, as the patient in the case was initially, the difficult airway algorithm can be followed using the “P’s of rapid-sequence intubation (RSI)” to maximize first-pass success: This is a slightly modified version of the P’s of RSI: Plan B, predict a difficult intubation or bag-valve mask, preparation, “preintubation” optimization, preoxygenation, positioning, paralysis, put to sleep, placement with proof, and postintubation management.
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