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%
Challenge
How should we manage the airway?
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?
Conventional LMA
LMA is a conduit
Fiberoptic Exam Through LMA
Intubating LMA
Intubating LMA
ProSeal LMA
Combitube
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
Other Devices
Cutting the LMA
Anesth Analg 2003;97:299-300
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?