True emergency surgical airways performed for genuine cannot intubate cannot ventilate/oxygenate cases are rare in clinical practice regardless of your background speciality. So when they occur and are published as case reports, its useful for those of us interested in learning to be the best at emergency airway management, to carefully review the lessons that can be gleaned from such reports.
In this case report in the Journal of Emergency Medicine, online Jan 2013, the authors from a San Diego hospital emergency department, describe their experience of encountering a difficult airway and initial failed multiple intubation attempts with eventual deterioration to a CICVO situation in a critically hypoxic patient with cardiogenic pulmonary oedema. They describe a unique complication of successful Seldinger technique cricothyrotomy with an uncuffed Melker cricothyrotomy catheter. Their novel approach to managing the complication successfully is useful to know.
Overview of the report :
A 67 yo man with past renal transplant, heart failure and coronary artery disease presents via EMS with acute respiratory distress. Initial exam is suggestive of flash pulmonary oedema with SpO2 readings of 60-90% on mask oxygen. Patient was obtunded . Decision is to intubate quickly and etomidate and suxamethonium is given. A Glidescope VL is used but despite 5 attempts by three physicians including an anaesthesiologist, there is a failure to intubate or even visualise the glottis, due to copious airway secretions and multiple pharyngeal polyps. After the 5 th attempt a CICVO develops and SpO2 falls to 60 % and mask oxygenation is a failure.
The decision is made to use the only dedicated surgical airway kit in the department, a 4 mm uncuffed Melker Seldinger technique cricothyrotomy kit. This is successfully placed and confirmed in trachea via colorimetric capnometer. SpO2 increases using BVM via the catheter to 90%. Over the next few minutes, resistance to BVM via catheter increases and a noticeable air leak via the mouth develops. This is managed using a double BVM technique with one mask BVM set placed over mouth and nose and synchronised ventilations with the BVM via cricothyrotomy catheter. This leads to SpO2 in high 90’s and a repeat Glidescope laryngoscopy allows a successful visualisation and intubation of the glottis. The Melker catheter is successfully removed after orotracheal intubation is achieved. The patient makes an uneventful recovery and is discharged 6 days later with no neurologic sequelae.
Lessons from the case report :
1.Failure of initial Glidescope videolaryngoscopy – the enemy of any VL or indirect laryngoscopy system are airway secretions and fluids, blood, vomit etc. Be careful if you know these conditions exist in the patient you are about to intubate. This is the second case I have read/heard of in the last 3 months where an indirect laryngoscope system failed due to airway secretions obscuring the field of view
2.Multiple intubation attempts precipitating CICVO – we all know there is reasonable evidence associating multiple intubation attempts with bad outcomes like death so why do we still do it? In human factors research its called task fixation. In high stress high risk situations, the brain can get locked into one train of thought and action. Remarkably there can even be a group reinforcement or so called Lemming effect. One person follows the unsuccessful action of the previous and so does the next. The individual fails each time but collectively as a group they reinforce the need to succeed at that one task. I think video laryngoscopy can make this task fixation worse in some cases. You would think VL may allow task fixation during intubation to be broken earlier i.e everyone watching the VL screen can see if the view is terrible or full of secretions, but I surmise that the intubation group can get fixated on the screen itself and become locked into a group goal of achieving the perfect glottis view on the screen. In this theory, each intubator who fails hands the VL system over to the next group member in the hope that they can get a better view on the screen. Its like a bunch of men trying to fix poor TV reception . Most will keep trying to adjust the screen and channel settings, even the antennae connection. They will do this almost always first, often for multiple attempts before either giving up or climbing on the roof to check the external antennae. This is human nature. We all do this, even women but I have noticed they often look for alternative approach earlier or at least ask for help earlier! This is the second case report I have reviewed whereby multiple VL attempts have eventually led to a CICVO requiring a surgical airway rescue.
3.Consider using a supraglottic airway rescue device earlier – No supraglottic airway device was used after failed orotracheal intubation attempts. Not only might this have avoided the need for a surgical airway but it probably would have solved the airway leak issue encountered subsequent to the surgical airway placement, as long as the SGA was left insitu as well.Several supraglottic airway devices are available now, disposable with gastric drainage channels as well as designed to blind intubate via.
4.Having the right gear to manage the difficult airway – The authors admit that since the case reported, their department has purchased surgical airway kit with cuffed airway catheters and they discuss the use of open cric techniques with bougie and cuffed ETT. They stress the importance of ED physicians knowing a variety of difficult airway techniques and being able to adjust for unexpected complications
Congratulations to the authors for a very useful case report and successful management of a difficult situation!
I encourage you to try to read the complete case report and here is the abstract link
Case report : dealing with a ventilation complication after successful cricothyrotomy