You are called urgently to the Emergency Department to review a 63-year-old male with chronic airflow limitation who is rapidly deteriorating. He is spontaneously breathing and a known difficult intubation.
Outline the priorities in this man’s management.
This is an emergency situation with the following key issues:
Rapid deterioration in a patient with airflow limitation
Preparation for a difficult intubation
Management comprises simultaneous resuscitation and assessment to diagnose the cause(s) of the rapid deterioration in this patient and initiation of supportive and definitive management and at the same time calling for help and preparing for a difficult intubation.
Prompt diagnosis and appropriate focussed management of the underlying cause(s) may obviate the need for intubation in this patient but should not delay intubation if this needs to be done.
Help should be sought from the most appropriate resources available (senior ED or anaesthetic colleague, ENT, skilled anaesthetic technician)
Diagnosis of underlying cause depends on history, examination and specific investigations. Possible causes of rapid deterioration in this patient include tension pneumothorax, worsening bronchospasm, pneumonia and septic shock, pulmonary embolus, myocardial ischaemia. Treatment measures may include thoracocentesis / insertion ICC, bronchodilators, fluid and vasopressor resuscitation and antibiotics, thrombolysis, reversal coronary ischaemia.
Consideration should be given to a trial of NIV but again this should not delay necessary intubation.
If the underlying problem is not readily reversible, proceed to securing the airway with preparation for difficult intubation.
Preparation for difficult intubation involves the following:
Patient unsuitable for transfer to OT so use well-equipped resus bay in ED
Standard intubation equipment plus difficult airway trolley including equipment for emergency surgical airway, resuscitation equipment and full monitoring and ETCO2
Sedatives, muscle relaxants, resuscitation drugs and local anaesthetics
Experienced assistants for airway equipment, drugs, cricoid pressure and general help Experienced colleague (ICU, anaesthesia, ED, ENT)
Assess patient’s airway and information regarding previous intubations and nature of difficulty and ease of bag-mask ventilation. It may be appropriate to perform immediate tracheostomy or cricothyroidotomy under local anaesthesia. Difficult to intubate BUT easy to ventilate increases options.
Whenever one is asked to "outline the priorities", one shoud probably begin with attention to the immediate ABCs of management.
After that, the priorities here are firstly the management of acute respiratory failure, and secondly the preparation for a difficult intubation.
Immediate attention to ABCs:
Management of respiratory failure:
Preparation for a difficult intubation:
A generic list of difficult airway equipment to have ready:
Hyperglycemic Comas by P. VERNON VAN HEERDEN from Vincent, Jean-Louis, et al. Textbook of Critical Care: Expert Consult Premium. Elsevier Health Sciences, 2011.
Oh's Intensive Care manual: Chapter 58 (pp. 629) Diabetic emergencies by Richard Keays
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