combined otolaryngology-anesthesia-emergency medicine difficult airway conference dowling...
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Combined Otolaryngology-Anesthesia-Emergency Medicine Difficult Airway Conference
Dowling AmphitheaterFebruary 12, 2007
Case
A 60 year old man, (80 kg, 5’8”) suffered a hemorrhagic stroke shortly after a full meal.
He was taken to a community hospital unconscious and with breathing difficulty. In the ER, endotracheal intubation with direct laryngoscopy was attempted several times unsuccessfully.
A laryngeal mask airway (LMA) was inserted and somewhat adequate ventilation was achieved. The patient was transferred to Boston Medical Center with the LMA in place, unconscious.
Physical Exam
• Unresponsive (GCS < 6) but not paralyzed• Hemodynamically stable• Husky, short neck• Mouth opening – difficult to evaluate• LMA #4 in place• Full dentition• Distended tympanic epigastrium• Distant breath sounds – ventilated with bag-valve• Hgb O2 Sat: 98%
Considerations
1. Fiberoptic assessment of larynx through LMA?2. How long can he remain apneic?3. Do we sit the patient up?4. Should neuromuscular blocking agents be used?5. Should a nerve stimulator be used?6. Insert NGT?7. Remove LMA?8. Attempt direct laryngoscopy again?9. Intubate through LMA?10. Cricoid pressure?11. Surgical airway?12. Control hemodynamics?
CT of the cervical spine showing an over-inflated distal balloon of the combitube (solid arrow), placed in the esophagus, severely compressing and narrowing the adjacent trachea (dashed arrow). From: Portereiko: J Trauma, Volume 60(2).February 2006.426-427
Combitube
Considerations
• Fiberoptic assessment of larynx through LMA?• How long can he remain apneic?• Do we sit the patient up?• Should neuromuscular blocking agents be used?• Should a nerve stimulator be used?• Insert NGT?• Remove LMA?• Attempt direct laryngoscopy again?• Intubate through LMA?• Cricoid pressure?• Surgical airway?• Control hemodynamics?
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