Same scenario. 2 different pathways – which are you taking?


60yr male arrives to ED in respiratory compromise, previous tracheostomy (now closed over), assaulted by son who’d stamped on his neck and chest fracturing ribs with likely pneumothorax.

(Old notes not available at time later reveal previous attempts to intubate under elective conditions in operating theatre were unsuccessful and describe a distorted epiglottis and extremely narrow upper airway)


Pathway 1
Critical care physician preoxygenates using face mask seal while collaborating intended plan to team
Patients airway intermittently obstructs, but supported by physician with capnography attached at this time indicating airway patent
O2 sats 98%
(Critical care physician wishes there was ETO2 monitoring to assess efficacy of what’s being done. Considers how sad it is we don’t have collaborative structures to drive system & equipment improvements)
Patient induced with propofol and Roc 1.2mg/kg
Attempts PPV at low pressure unsuccesful
Attempts intubation with McGrathMAC – team see a swollen distorted epiglottis, glottis comes in to view while assistant performs tracheal manipulation under vision – very narrow glottis to narrow for even narrowest ETT. Physician declares failure to intubate.
Informs surgeon high likelihood of need for surgical airway. Surgeon asks nurse for ‘Scalpel, bougie and size 6 ETT’ and starts palpating patients neck.
Physician attempts PPV with mask, guidelines in situ, then SGA – all fail. Then tells surgeon that ‘we need a surgical airway’
Surgeon successfully achieves surgical airway, confirmed with capnography, O2 sats remained 98% throughout.


Pathway 2
Critical care physician preoxygenates with NRM & NC (unable to use capnography as no seal and high flows)
Intermittent airway obstruction goes unrecognised
O2 sats start falling 95%
Collaborates with team relays intended plan
Elects to use direct laryngoscope for intubation
Patient induced with propofol and Roc 1.2mg/kg
No attempts made to PPV made in time between induction medications given and laryngoscopy
Attempted laryngoscopy Grade 3 view
Physician grabs assistants hand and gets them to try to push their hand in direction for tracheal manipulation. Without feedback of direct visualisation this creates tension between tphysician and their airway assistant
Grade 3 view persists
Physician asks for bougie
Attempt to insert bougie causes some trauma to airway
Bougie inserted & ETT railroaded
Physician asks for BVM. NRM disconnected from wall O2 and BVM attached & handed to physician who attaches to ETT. Not sure if ETT in trachea – nurse attaches capnography. No trace. Physician asks if capnography has been working recently but has foresight to assume oesophageal intubation. Removes ETT and asks for VL. O2 sats 91%. While waiting for VL attempts again with DL notes still Grade 3 view with bloody airway.
Grabs VL – again poor view, little improvement with tracheal manipulation. Second more senior ED consultant steps in and attempts intubation O2 sats now 87%. BVM connected – again no capnograph trace (ED consultants both comment about whether capnograph working recently)
O2 sats 75% and falling rapidly. ETT removed. Face mask ventilation attempted, then assisted with guedel unsuccessful. Attempt with SGA – no recordable capnograph trace O2 sats 45, Senior ED consultant asks junior ED consultant to auscultate chest – stethoscope obtained. Difficult to auscultate – team informed to be quiet. O2 sats 35. Patients pulse rate drops significantly. NIBP cycles – unable to record. ED consultant attempts to palpate pulse – no discernible pulse. Asks for cardiac compressions to commence and adrenaline administered. Senior ED Consultant says ‘Seeko’ – some members of team appear confused by statement. ‘KIKO’, ‘FONA’. ED nurse grabs walkabout phone and hands to ED consultant who gives her a look as if he wants to hurl the phone across the room. Junior ED reg realises what he means grabs the ‘CICO kit’ which is opened up. Rapid discussions are had as to weather to use the needle introduction kit or scalpel. Scalpel is chosen – surgical airway made slightly more difficult while cardiac compressions performed. Surgical airway obtained. BVM attached – capnography trace appears but ETCO2 low due to poor cardiac output.
Cardiac output established, patient on adrenaline infusion. Airway, breathing, circulation stable. Patient spends 4 days in ICU – no response from patient despite no sedation. Decision to extubate patient. Cause of death – hypoxic brain injury.
M&M presentation Comments made included:
– Should have attempted laryngoscopy with VL first. This leads to heated debate about evidence of VL vs DL which is left unresolved – the junior ED doctors not wanting to upset their superiors given the potential impact this might have on their future careers
– Everything was done according to difficult airway guidelines & that it was appropriate to have attempted a surgical airway. The adverse outcome was inevitable and could not have been avoided.

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