LEARNing Rounds: Lessons Learned From An Unanticipated Difficult Airway or “Oops, I Need Fresh Underwear!”

Learn, Evaluate, Adopt…Right Now!

Colin G. Kaide, MD, FACEP, FAAEM // Editor Michael G. Barrie MD

LEARN airway word document version of this resource

Case

This patient was an obese male in his 50’s who developed respiratory failure in the ED.  Intubation by a senior resident and a very experienced attending using first GlideScope® (GS) then direct laryngoscopy (DL) were unsuccessful.  They placed a size 5 LMA and were able to successfully oxygenate the patient.  I was called to assist with the airway.  They said they could visualize the cords with DL and with the GS.  They were unable to guide the ETT into position because of what was described as a large amount of “redundant tissue” and some anatomic issue that prevented 2 experienced doctors from guiding the ETT thru the cords.

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Conference Notes cont…

This is part 2 of my review of Dr. Maloney’s lecture on “The Critically Ill Neonate in Your Community ED.”

After introducing the Pediatric Assessment Triangle, Dr. Maloney reviewed some unique considerations with pediatric ABC’s.

Airway

1.  Because of the baby’s big occiput and flexible neck and trachea, use a shoulder roll to help with visualization

2. Babies have a higher, more anterior glottis, so “look up, pull back”

3.  Used cuffed tubes for any pediatric intubation.  This is a change from previous PALS guidelines

Breathing

1.  Disable the “pop-off valve.”  Instead, watch for chest rise and let that guide your bagging

Circulation

1.  IO is the preferred method for access in a sick baby.

2.  The umbilical vein can be used up to 7-10 days.  Use a 20 gauge angiocath or 5 French feeding tube. Continue reading