Emergency physicians usually respond to in-house cardiopulmonary arrests, and each case is somewhat the same. You arrive at the bedside with no information about the patient, and must quickly assess the situation via a combination of nurse report and a focused patient exam. Securing an airway in cardiopulmonary arrest is critical to the resuscitation, and the EP should be the most skilled at this task.
This was put to the test in our hospital recently. A 70-year-old, 54 kg woman with a history of end-stage renal disease (ESRD) had been admitted to our hospital with marked hyperkalemia. She had undergone emergency dialysis uneventfully, and shortly after she returned to her room, the nurse found her foaming at the mouth and unresponsive. A “Code Blue” was called overhead. The emergency physician arrived to find the patient unresponsive and the respiratory technician assisting her respirations with a BVM. The patient's vitals were normal, and saturation was at 100%. The house supervisor reported that the patient had suffered a respiratory arrest, but she remained unresponsive and showed no signs of regaining consciousness. The decision was made to intubate her to protect her airway.
The patient was given an appropriate dose of IV succinylcholine, and her mandible was noted to be fixed and immobile. The space between the upper and lower incisors was no more than 1.5 cm, barely allowing through the tip of a Yankauer suction catheter. No immediate explanation was found in the patient's chart. Fortunately, the patient's vitals were stable and saturation was good. It was clear that a normal adult laryngoscope was not going to fit, so a Mac 1 blade was tried. It was gently squeezed through the teeth, and elevated the tongue enough to see the hypopharynx, but it was too dark, and the larynx could not be seen. A pediatric GlideScope was brought to the bedside, and the light was stronger because of its angled shape, but it illuminated the tongue rather than the hypopharynx.
Nasopharyngeal technique is recommended in difficult airways in an awake and cooperative patient. The patient had been paralyzed with succinylcholine, but she was starting to take breaths on her own, so it was deemed reasonable to attempt a nasopharyngeal intubation by timing the intubation with the patient's spontaneous inspirations while watching her abdomen distend. This technique was, unfortunately, also unsuccessful. By this point, an anesthesiologist responded to the overhead page and came to the bedside. He also attempted to intubate the patient with direct laryngoscopy without any success. He also tried using the GlideScope, and could not intubate the patient. A fiberoptic flexible bronchoscope was brought to the bedside for the anesthesiologist. Even this technique failed to secure the airway.
The anesthesiologist then suggested the retrograde wire technique. An 18g angiocath was inserted through the cricoid membrane, and a wire was passed through it. The anesthesiologist, however, was unable to pass the wire up to the oral cavity. Subsequently, the EP repositioned the needle more caudally, and was able to pass the wire down the trachea. It was clear by this time that a cricothyrotomy was the only choice left to obtain an airway on this patient. A 2 cm vertical incision was made at the midline alongside the wire. A short incision was made horizontally in the cricoid membrane. There was a small amount of bleeding. The cricothyrotomy kit had an uncuffed tracheostomy tube, and it was placed in the trachea easily over the wire. Now, for the first time in the patient's resuscitation, she started to desaturate. Air was leaking around the uncuffed cricothyrotomy tube and out of her mouth. By making some adjustments to the BVM-assisted ventilation, the patient's saturation improved.
A Shiley #6 tracheostomy was tried, but it was too large. A Shiley #4 tracheostomy was found just as the general surgeon came into the room. He assessed the neck, and to everyone's collective relief, placed the Shiley tracheostomy easily into the patient's trachea. The patient's saturation normalized, and she was transferred to the ICU. A week later, she had a permanent trach placed, and is alive two years later.
The first lesson here is to expect the unexpected. It was a complete surprise to the EP to discover that the patient's jaw was essentially fused (later linked to previous TMJ surgery) but only after the patient was given the paralytic. One of the basic concepts in difficult airway management is to avoid paralytics if the EP feels uneasy or less than confident about securing an airway, such as if the patient has a short and thick neck with a large tongue and small mouth. If that patient were to be paralyzed, all that head and neck soft tissue would collapse and completely obscure the view. Not paralyzing the patient at least maintains what oxygenation and ventilation the patient's own respiratory drive permits until a definitive airway can be secured.
Secondly, be very familiar with different techniques of emergent airway management. When confronted with the unexpectedly difficult airway, the EP's entire airway management toolbox must be used. Six different techniques were tried in this patient: direct laryngoscopy, GlideScope laryngoscopy, nasal intubation, retrograde wire intubation, fiberoptic intubation, and cricothyrotomy. The surgical airway ultimately succeeded, but any of the other techniques could have worked. Know several airway techniques, and try them all if necessary.
Third, don't hesitate to call for help. Anesthesiology and general surgery were paged STAT overhead very early on because it was quite clear to the EP that this was an extraordinarily difficult airway. The occupants of the house of medicine love to make fun of each other, but collegial collaboration in an unusually difficult airway such as this case resulted in saving the patient's life.
How many doctors does it take to perform a cricothyrotomy? Apparently, it takes three: an emergency physician, an anesthesiologist, and a general surgeon.