Postoperative Neck Hematoma

Postoperative neck hematoma is not often discussed in emergency medicine but behaves a lot like neck trauma, because it is neck trauma. These patients should be managed with a high-resource approach and discharged reluctantly, after careful deliberation.

Adapted from Bittner, MD.

The Paper Throat: A Lo-fi, DIY Laryngoscopy Simulator

 

Laryngoscopy involves a series of unnatural movements and hand-eye skills that are not easily learned while simultaneously caring for a dying patient. The Paper Throat is a low fidelity but high yield direct laryngoscopy training tool that is easily assembled and practiced. The hope is that routine use will generate laryngoscopy muscle memory so that training providers can focus on other aspects of airway management when called upon to intubate IRL.

Conceived and produced by Jonas Pologe.

Pulse Ox Lag

Folks put a lot of stock in the pulse oximeter, as they should, because the pulse ox is an awesome feat of engineering and patient safety. But the pulse ox lags.

Here, the inestimable Dr. Jonas Pologe (rhymes with apology) demonstrates pulse ox lag with a breath hold.

Breath hold starts at 0:11, sat is 100%
Saturation starts to drop at 0:48
Breathing commences at 1:25, sat is 82% at this point
Saturation continues to drop until 1:46, then recovers from its nadir of 77%
At 1:58, saturation reaches 100% again

 

Lessons:

1. When the sat is on its way down, the patient is more hypoxic than the pulse ox shows. This is another reason why, when laryngoscopy is not producing an acceptable view of the glottis, you should come out and reestablish ventilation/oxygenation earlier than you think. A more important reason to come out and bag early is described here.

2. When you are reestablishing oxygenation (using a bag mask, laryngeal mask, or endotracheal tube), do not use the pulse ox to judge the adequacy of ventilation, use capnography. That means the capnogram should be attached to the bag mask/LMA/ETT before the first breath is given. If the capnogram is good, ventilation is good, and the pulse ox will catch up, so relax and stop bagging so quickly.

When RSI isn't the Right SI

When RSI Isn't The Right SI.001

Rapid sequence intubation, the simultaneous administration of a paralytic and induction agent immediately followed by laryngoscopy, provides the optimal view of the glottis and prevents emesis. RSI is the best strategy for most patients who require intubation, but not all.

When you’ve decided to intubate, first maximally preoxygenate. If the patient will not cooperate with your preoxygenation plan, even after you’ve asked nicely, that’s your cue to add cooperation in a vial, ketamine, and then oxygenate, before you push the paralytic and intubate. This is delayed sequence intubation. Otherwise, carry on with preoxygenation, and consider a couple of special situations.

The first is the patient who is about to arrest–obtunded, no blood pressure. Any induction agent will cause sympatholysis which, along with the transition to positive pressure ventilation, may precipitate arrest, so ideally we would avoid both while the patient is in the state of nearly arrested. Resuscitate aggressively with fluids, vasoactive drips and treatment of the underlying problem for as long as you can before intubating. If you must intubate the patient who is obtunded with no blood pressure, the safest way to do it is often without any drugs at all, while the patient continues to breathe. If you have to give meds, dose sedatives low and paralytics high.

The next special situation is the patient who has a severe oxygenation or ventilation deficit. The severe oxygenation deficit patient saturates less than 90% on 100% NIV; the severe ventilation deficit patient is compensating for a severe metabolic acidosis, e.g. DKA with pH 6.7. In patients with a severe oxygenation or ventilation deficit, even a brief period of apnea is very dangerous, and since paralysis is certain to cause apnea, it stands to reason that paralysis may not be the best approach. However, these patients are very ill, so conventional awake technique, which requires time and cooperation, will not work well. If only there were a drug that would immediately render the patient tolerant of laryngoscopy, while ventilation and airway reflexes are preserved.

Ketamine-supported intubation, KSI, is pushing an induction dose of ketamine over 20-30 seconds, then performing laryngoscopy. KSI is awake intubation with minimal or no local anesthesia, or, if you prefer, RSI without paralysis.

By omitting the paralytic, KSI carries a chance of two harms: suboptimal view of the glottis, and emesis/aspiration. I address these harms in detail in this discussion; the advantage in glottic exposure offered by paralysis is less significant in the era of video laryngoscopy, which almost always provides a great view of the cords, and the risk of emesis/aspiration is very small most of the time. In any case, these harms must be weighed against the harm of apnea for the patient in front of you. Others have described a similar strategy, augmenting ketamine with etomidate as necessary.

The last and most important special situation is high concern for difficult laryngoscopy. You assess all your endotracheal tube-requiring patients for difficult laryngoscopy, either intuitively or explicitly, and most of the time, you think, I got this, in which case, carry on with RSI like you always do. But if you think it is likely that laryngoscopy will fail, and the patient is presently benefiting from their own ventilatory efforts, abolishing those efforts with RSI may not be the best choice.

Even in scary laryngoscopy cases, RSI is probably still optimal if the patient is high risk to vomit (has been vomiting, upper GI bleed, bowel obstruction). In these scenarios, the protection against emesis afforded by paralysis is compelling, so proceed with RSI, but use a double setup, with your partner on standby, ready to cut the neck. Keep the head of the bed up and drop an NG tube in beforehand if you can.

The patient whose airway is a lawyer’s dream and isn’t a particular risk to vomit is ideally intubated without a paralytic, while continuing to breathe, awake intubation. Awake intubation has two pharmaceutical arms: local anesthesia, and systemic sedation. The more cooperative the patient and the less urgent the airway, the more you can rely on local anesthesia. So if you have time and cooperation, dose glycopyrrolate or atropine, then generously nebulize, topicalize, and atomize lidocaine, then you can slowly, carefully do your laryngoscopy, or flexible endoscopy, or whatever you want, as the patient is awake and breathing. In the OR, where patients and physicians are stable and cooperative, patients with concerning airways are intubated with minimal or no sedation at all, which affords an enormous margin of procedural safety. Patients being intubated in the ED are of course neither stable nor cooperative, but a similar degree of safety can be achieved using ketamine: the less time and less cooperation, the less lidocaine, the more ketamine.

In the extreme version of the emergency department awake intubation, give induction dose ketamine and go: KSI. Consider KSI for your severe oxygenation/ventilation deficit patients, but also when you are concerned that laryngoscopy is going to fail and the patient won’t cooperate with, or you don’t have time for, a more civilized, operating theater-type awake intubation. Have a paralytic ready in syringe, in case you want to convert to RSI at any point, and incorporate a double setup component to your approach, because your concerns about laryngoscopy might turn out to be well-founded.

Awake Intubation: A Very Brief Guide

 

 

Awake intubation is placing an endotracheal tube in the trachea while the patient continues to breathe. The principle advantage over RSI is that you do not take away the patient’s respirations or airway reflexes, which makes the process safer in many circumstances. The disadvantages are that the patient’s personality and movements, as well as the patient’s airway reflexes, must be managed, which takes time, and even when done well, the view you get won’t be as good as in a paralyzed patient.  Instrumenting the back of the throat may cause gagging and possibly vomiting, though this is quite unlikely to lead to clinically significant aspiration (because the patient is awake).  The more difficult airway features, and the less urgent the intubation, the more likely you should intubate awake. Patients who are at high risk to vomit are not good candidates for an awake technique.

The two arms of awake intubation are local anesthesia and systemic sedation. The more cooperative your patient, the more you can rely on local; perfectly cooperative patients can be intubated awake without any sedation at all. More commonly in the ED, patients will require sedation. Ketamine is the agent of choice in most circumstances, as it sedates without depressing respiration or airway reflexes. In somewhat cooperative patients, 20 mg boluses, titrated to effect, work very well. In very uncooperative/agitated patients, a full dissociative dose (1.5 mg/kg) is an effective strategy though a brief period of apnea is usual if dissociative doses are delivered as a bolus, and laryngospasm is a possible complication. For those patients where raising heart rate or blood pressure is undesirable, benzodiazepine sedation will have a less effective but still salutary effect. Dexmedetomidine is probably a better agent in these scenarios, but is a little tricky to use and not available in most EDs.

Even if using full dissociative dose ketamine, do your best to anesthetize the airway, using the steps listed in the box above, excerpted from the ED intubation checklist. Local is much facilitated by a dry mucosa, so the first step, if possible, is to dry the mucosa with glycopyrolate or atropine, followed by suction and dabbing with gauze. Once this is done, anesthesia is delivered by nebulization, atomization (ideally using a purpose-built atomizer like a MAD device), and drip techniques.

Once the patient is adequately anesthetized/sedated, you gently proceed with your intubation method of choice. When you see the cords, you can pass the tube without paralysis, place the bougie and then paralyze, or paralyze before placing the bougie/tube. I recommend the second option, and I also recommend that you prepare to do a full RSI, with whatever equipment and drugs you would use in an RSI case.

When done well, awake intubation is quite anticlimactic, as the patient simply continues to breathe, and saturation is maintained, for as long as needed. While RSI is terrific and will work very well in most cases, if you perform RSI on a patient who was a good candidate for an awake technique, and it doesn’t go well, you have made a consequential mistake. Awake technique requires little additional skill; it is under-utilized in emergency medicine because it requires what emergency providers often lack: patience. In this case, however, patience is well rewarded.

The Role of Percutaneous Cricothyrotomy: Wire In Trachea Readiness Technique

There was a period in the history of emergency medicine when cricothyrotomy was the primary airway management strategy for all patients in cervical spine precautions. We have since learned that most of these patients can be intubated orally, but in the intervening years have lost our nerve when it comes to using the neck for airway access. Today, everyone agrees that the most important error around emergency cricothyrotomy is that it is performed too late [1, 2, 3]. An unsuccessful cricothyrotomy performed at the right time is defensible; a successful cricothyrotomy performed too late is indefensible. Both lead to terrible outcomes: one is good, defensible care, the other is poor, indefensible care. The pivotal element in emergency surgical airway decision-making is giving yourself permission to initiate the procedure before the patient is dead.

Guidewire

 

The Cricothyrotomy Menu

There are a variety of strategies for accessing the trachea via the neck and the terminology is confusing. Open cricothyrotomy, often referred to as surgical cricothyrotomy, is using a knife to cut a hole in the cricothyroid membrane and placing a tracheostomy tube or endotracheal through that hole. Several techniques have been described, including the no-drop technique, the rapid four-step technique, and the scalpel-bougie technique.

Percutaneous cricothyrotomy is a term usually used in distinction to surgical or open cricothyrotomy, implying a less invasive approach. Percutaneous cricothyrotomy facilitates the placement of a tracheostomy or endotracheal tube in the trachea by using either a Seldinger tube-over-dilator-over-wire technique, or a tube-over-trocar device [1, 2]. Most emergency physicians are referring to the Seldinger technique when they use the term percutaneous cricothyrotomy.

Though a needle is used in the Seldinger technique, the term needle cricothyrotomy usually refers to a less definitive procedure where a comparatively small cannula, such as a 14g angiocath, is placed into the trachea and oxygen is insufflated under pressure through the cannula; this is called transtracheal jet ventilation when a special high-flow device is used, though a bag-valve-mask is more likely to be available, if less effective, and several hard to remember maneuvers are commonly proposed that allow a BVM to be adapted for this purpose.

Wire In Trachea Readiness Technique

For patients who suddenly and unexpectedly cannot be intubated or oxygenated, the weight of evidence and opinion seems to favor an open technique [1, 2, 3, 4, 5], which appears to be faster than a percutaneous approach, more likely to be successful for those who don’t perform the procedure often (i.e. everyone), and would be used to rescue a failed percutaneous attempt. Smart people disagree on this point, however. Certainly, the goal in these scenarios is to establish oxygenation as quickly as possible by whatever means necessary, and that will differ based on provider, patient, and setting. Have a plan that works for you in your environment.

Many patients who cannot be intubated orally do not suddenly and unexpectedly crash, however. The need for a surgical airway can present itself as a land mine that explodes in front of you as you walk to your mailbox in your bathrobe, but also as a land mine that explodes as you carefully traverse a known minefield in a tank. Of course every emergency intubation is a minefield, and being cognitively and materially prepared for failure of intubation and failure of ventilation at the outset of every case is one of the characteristics of the airway expert. But while we have many options for plan A and plan B, there is still only one plan C – when intubation fails, and oxygenation fails, plan C is cricothyrotomy. Since it is clear that the most important surgical airway error is that it is delayed, several airway management paradigms [1, 2, 3] have recently emerged that explicitly encourage providers to prepare for and properly initiate cricothyrotomy.

In Scott Weingart’s CricCon taxonomy, the highest alert posture is to cut the skin and find the membrane, so that if the need arises, incising the membrane and placing the tube is simple. Most emergency practitioners, however, are uninterested in cutting the neck. On the other hand we are perfectly happy to put wires and tubes in the neck, and do it all the time in the internal jugular vein. Here lies the role of percutaneous cricothyrotomy: not as a crash technique, but as an alert posture, a readiness maneuver: when the likelihood of requiring a surgical airway is sufficiently high, place a wire in the trachea.

Placing a wire in the trachea feels more like inserting a central line than cutting the neck. Feel free to use ultrasound. [1, 2, 3] The strength of the wire-in-trachea approach is that it lures the practitioner into preparation and makes timely performance of cricothyrotomy more likely by breaking the procedure into agreeable steps. Inclination via incrementalism.

There are at least two scenarios in which wire-in-trachea readiness technique would be used:

a. An almost crash expected very difficult laryngoscopy, such as an angioedema patient who requires an airway not this very second but urgently.  If the patient is cooperative, wire is placed after rapid local anesthetic infiltration as preparations are being made for awake laryngoscopy vs. RSI. If uncooperative, wire is placed immediately after induction (concurrent with preoxygenation if using a delayed sequence strategy), just before laryngoscopy, or as laryngoscopy is beginning. This is basically an enhanced double setup.

b. In the midst of a can’t intubate, can ventilate situation. This occurs relatively commonly: laryngoscopy has failed, but LMA or bag-mask ventilation is effective, then the second laryngoscopy attempt fails, but ventilation remains effective, and then the third attempt fails, and you feel like you’re running out of tricks/tools. And you know that with every airway attempt, the glottis becomes a little more swollen, the airway gods–who have until now granted you the gift of ventilation–their patience is a little more tested, and the prospect of can’t intubate, can’t ventilate looms. So after a few failed oral attempts, while the patient is being ventilated, place the wire, then go on with as many further attempts as you want, knowing that if and when ventilation becomes ineffective (or if you have other patients to see and want to move on), cricothyrotomy is straightforward.

Logistics

Percutaneous cricothyrotomy kits are expensive and often stocked in small numbers. To utilize the wire-in-trachea readiness technique, use the needle/syringe/wire from a central line kit. Fill the syringe halfway with water/saline so that tracheal location of the needle can be confirmed by the bubbling of aspirated air.

Have your unopened percutaneous cric kit at the bedside, and when needed, 1) open the kit 2) stab the skin with the scalpel 3) slide the tracheostomy tube-over-dilator into the trachea 4) pull the wire and dilator 5) inflate the cuff 6) ventilate. Don’t forget to load the tracheostomy tube onto the dilator if not pre-loaded in your kit.

Step 2 is important: an aggressive stab must be made on the skin, along the path of the wire, similar to central line technique but larger, to accommodate a larger device.

Step 3, inserting the tube-over-dilator, is facilitated, like everything else, by the application of sterile lubricant. Use a firm twisting motion.

If oral or nasal access is successful and cricothyrotomy isn’t needed, simply pull the wire. Put a band-aid on the site; this will serve as evidence of a disarmed land mine.

emupdates ETI Plan ABC

 

Thanks to Rob and Scott for helping me develop this idea.