Let me preface this case by saying that whenever any of our excellent 2nd year Emergency Medicine residents cannot get a tube, I get a little (a lot) nervous.
Here is the case:
84 year old male, MVC rollover arrives via life flight following needle decompression of left pneumo en route. Normotensive.
Mild increased work of breathing, very tender left chest wall, sats 94% NRB, he had additional soft tissue extremity injuries requiring operative debridement, CXR showed multiple left sided rib fractures, no visible pneumo on CXR)
Pt placed in reverse Trendelenburg 15 degrees head up, NRB flow rate 30L/min, nasal cannula on, and turned up to 15L after sedative and paralytic meds pushed.
200mcg of fentanyl given en route, another 50 mcg given on initial assessment.
Ketamine 1mg / kg, Roccuronium 1.25 mg/kg
Initial attempt by resident with glidescope (due to C-spine immobilization) gave a grade 2 view of the larynx. His mucosa was very tacky, and there was a moderate amount of tenacious saliva that cleared with suction. Despite multiple attempts at repositioning the tip of the ETT, tube delivery was unsuccessful. There was an estimated 2 minute safe apnea duration on the VL attempt prior to sats hitting 90%, when the glidescope was withdrawn, and he was BVM ventilated back up to sats of 98%, (this took about one minute)
On DL, I had a grade 1 view, bougie was used due to the grade 2 view on VL, ETT tube passed over bougie without difficulty.
Post intubation fentanyl 1 mcg/kg bolus and fentanyl drip for sedation.
This case illustrates the difficulties with tube delivery using VL. There was a reasonable view of the larynx, but do to the tackiness of his mucosa, tube delivery was extremely challenging, even in the setting of great pre-oxygenation, and a lengthy safe apnea duration.
I would still try VL first in c-spine immobilized patients, however would switch to DL earlier next time.
I believe we need to be proficient at both DL and VL, and this is a case that demonstrates this point well.
I attached my idiots guide to apneic oxygenation.
Rob Bryant MD
Utah Emergency Physicians
801 633 8453
(Editor’s comment (Minh) – Note to self. Don’t throw direct laryngoscope just yet. Might still be useful)