Intubations this month: 21
Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentation for March 2018. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.
Focus on: Airway Management in the Septic, Hypotensive Patient
We have previously discussed the guidelines for intubation of the critically ill from December 2017.
- Guidelines for the management of tracheal Intubation in Critically Ill adults. Higgs A et al. BJA 2017. Doi: 10.1016/j.bja.2017.10.021 ::: [PDF – open access]
The authors suggest that peri-intubation haemodynamic management and the prevention of hypotension/cardiac arrest at induction can include:
- Addressing causes of hypotension in the patient
- Drug choices – Ketamine & Rocuronium
- Rapid volume replacement available with institution of IPPV
- Vasopressor/inotrope boluses available
- Vasopressor infusion before induction
It is prudent to increase the noradrenaline infusion rate on any septic, hypotensive patient with noradrenaline running before RSI drugs are administered. Likewise, adrenaline boluses (10mcg/ml & 100mcg/ml) should be prepared before RSI drugs are given. A rapidly flowing IV access line is useful to ensure drugs reach the circulation but also to be able to offset the physiology change of reduced preload with IPPV.
Video Focus: Other Things You Might See in the Airway
These two videos [password: AiRblogVideos] show some laryngoscopy findings in burns patients.
The first (very short!) shows soot, on the face as the CMAC is inserted and on the cords at laryngoscopy.
The second shows very mildly sooty snot in the airway of a patient with 35% TBSA burns just before the epiglottis is visualised. Sooty snot on nose-blowing was part of the rationale for intubation in this patient.
Other Things You Might See
This video shows the appearance of a single (right sided) NPA during passage of the CMAC laryngoscope through the oropharynx.
This video shows the appearance of bilateral NPAs during passage of the CMAC laryngoscope through the oropharynx.
This video shows the appearance of a denture plate during passage of the CMAC laryngoscope through the oropharynx. This is not secured and should be removed; it’s easy to see how it could cause a complete airway obstruction.
In this video, the presence of blood in the airway in combination with the use of the LUCAS device to provide CPR means that the view is totally lost when the blood hits the camera.