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PHARM Podcast 28 – My first emergency surgical airway with Dr Jordan Schooler

 

Hi folks! This episode , as part of Surgical airway month of July 2012, I interview Dr Jordan Schooler an EM Resident in USA. He has just recently completed internship and was doing his first ICU resident shift when a patient with angioedema gets admitted from the ER to his ICU. Its a night shift and all goes well till 0400hrs. Tune in and hear of what happens next.. Read of Scancrit.com’s first emergency surgical airway experience and practice lessons from that too!

Minhs’ tips for acute angioedema

  1. These can be tricky as they may appear fine initially. It all depends upon the cause
  2. Adrenaline responsive vs adrenaline unresponsive. Scott and I are planning a podcast on this issue of angioedema so stay tuned
  3. Regardless, all these cases may end up needing urgent surgical airway. Prepare and plan. Use CricCon strategy
  4. Agree upon an airway leader and a decision point to be triggered for proceeding to do surgical airway.
  5. Use a double setup strategy with one provider trying orotracheal intubation or SGA placement and one provider going through the neck. Stay safe and enjoy the interview Minh

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

6 Comments Post a comment
  1. Great talk and thanks for sharing.

    I’ve certainly had some interesting cases of none anaphylactic angioedema over the years, some more dramatic then others.

    There are so many controversies regarding targeting bradykinin pathways, antihistamines, steroids, adrenaline vs no adrenaline and use of C1 concentrate in HAE +/- others. But what strikes me most about the condition is the inconsistency in management planning amongst clinicians and when to intervene or not. Currently we rely on experience and an educated judgement on the likelihood of disease progression. The paper below is quite nice as it outlines a grading system with corresponding management algorithm (ACEi related). Discharge, observe, flexible fibrescopic assessment, treat, intubate etc. While I’m always a little hesitant to suggest grading/algorithms are a good substitute for experience a think it provides at least a structure to a complex pathophysiology. The trick is to know when to bend the rules when the little voice in your head is telling you something is not right.

    Interesting points-

    Diverse aetiology
    High incidence of angioedema with ACE-i and low airway intervention rates.
    Angioedema with ACEi can occur very late after initiation, as much as 10 years+.
    What you see from the outside is not always reflective of what is happening in the supra glottic and glottic region.

    http://www.annals.com/toc/auto_abstract.php?id=13276

    http://www.annals.com/toc/auto_abstract.php?id=15646

    Keep the podcasts coming.

    Pete

    PS thanks for the vividtrac Minh, I will let you know what I think over the coming weeks.

    July 17, 2012
  2. thanks Peter
    Very good points all round and we hope to produce a podcast on this as it can be challenging as you suggest. In my region we have a family who have C1q esterase deficiency and a number of them have had serious complications of the illness. So my colleagues and I have become very up to date with the latest details of the condition, including use of C1q concentrates, TXA, FFP and the novel antagonists , icatibant. Two vials of this are stocked at the remote clinic where this family resides. We have had occasion to use it at least once I am aware of with dramatic reversal of airway swelling.
    ACEI assoc angioedema can be very sneaky condition and very deadly as a result. Because it is a medical condition, it can be very tempting to throw everything at it to stave off the need to do an airway intervention. It gets back to that crucial trigger point we talked about in the podcast, about declaring and diagnosing an airway emergency and proceeding to surgical airway. Making that decision is incredibly hard, even for seasoned providers.

    What you suggest about possibly having an awake laryngoscopy as part of your initial and ongoing assessment of patients with angioedema or suspected upper airway pathology, may be a very useful skill to have and perform. there was a recent case of what turned out to be an epiglottis abscess but initially sold as Ludwig’s angina, that a retrieval registrar was tasked to transport to a higher level hospital. Patient seemed fine on handover so decision to observe only for transport. Rapid crash deterioriation and loss of airway with resp arrest ensued but they were able to BVM rescue oxygenate and larygnoscopy revealed very abnormal airway anatomy. With great skill, registrar able to pass bougie in correct hole.

    Perhaps with an awake upper airway exam, this might have revealed the true nature of the pathology and led to preparations for double setup RSI attempt prior to transport. Or with your cool GSA HEMS airway pack, Peter, you could use that shiny new Ambu Ascope and iGel combo under topical LA and ketamine?

    July 17, 2012
  3. amazing story!!!!

    July 18, 2012
  4. Excellent podcast Minh, well done Jordan!

    Stories like this are great to ‘legitimise’ what we know we can, and should, do in these life threatening situations.

    Hearing from someone who has successfully undertaken such a procedure with the benefit of online education, makes it much easier for the next person who may be wondering: can I? Should I?

    Thanks!
    David

    August 4, 2012
    • thanks mate. Excellent article on thoracotomy in the ED on Andy’s blog ,right back at ya!

      August 5, 2012
      • Cheers Minh, it’s the same point. Hearing first hand from others experiences is so much better than textbooks etc… #FOAM all the way!

        August 5, 2012

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