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.
- Plan A: attempted intubation under direct laryngosopy optimizing position and using adjuncts and if fails:
- Plan B: Intubating LMA and if fails:
- Plan C: able to ventilate via LMA, controlled surgical airway OR if unable to ventilate via LMA emergency surgical airway (cricioidotomy or cricoidostomy)
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:
- Assessment of the need for immediate intubation
- Support of airway with airway adjuncts eg Guedel or nasopharyngeal airway
- Support of oxygenation with high-flow oxygen and/or NIV
- Assessment of coexisting circulatory failure with rapid bedside TTE and lung ultrasound to exclude immediately reversible causes eg. pneumothorax and cardiac tamponade or acute decompensated heart failure
- Support of circulation with appropriate vasoactive agents
Management of respiratory failure:
- Detailed history and thorough physical examination
- ABG, ECG and CXR +/- CTPA (if permited by patients condition)
- Support of oxygenation with titrated FiO2
- Support work of breathing with NIV
- Support ventilation by titrating NIV pressures to enhance CO2 clearance
- Manage bronchospasm with bronchodilators and steroids
- Manage infective aetiology with appropriate antibiotics
Preparation for a difficult intubation:
- Transfer patient into controlled monitored environment - resus bay, ICU or operating theatre
- Contact appropriate airway experts - a senior anaesthetist and ENT surgeon are sensible consults
- Organise the difficult intubation equipment trolley
- Prepare skilled staff to assist
- Prepare equipment and brief patient regarding the need for intubation
- Assess the airway and investigate past history of intubation to determine what equipment was required in previous instances
- Options for intubations:
- Awake bronchoscopic intubation is the gold standard
- If the expertise for this is not available:
- Plan A: Video-assisted laryngoscopy with availability of gum elastic bougie
- Plan B: insertion of intubating LMA and intubation via LMA or ventilation with LMA until the necessary expertise becomes available
- Plan C: percutaneous cricothyroidotomy or formal surgical airway
A generic list of difficult airway equipment to have ready:
- A selection of oropharyngeal airways
- A selection of nasopharyngeal airways
- Macintosh laryngoscope blades size 3 and 4.
- Alternative laryngoscope blades (eg. a Kessel blade)
- A short laryngoscope handle (for fat or big-breasted people)
- An endotracheal tube introducer
- A malleable blunt atraumatic stylet.
- Normal LMAs of different sizes
- Intubating LMA kids, eg. Fastrach
- A selection of specialised ETTs, eg. long flexometallic, nasal, etc.
- A long airway exchange catheter.
- A surgical cricothyroidotomy kit
- A kink resistant cricothyroidotomy cannula and jet ventilation kit
- A capnograph, capnometer or colorimetric end-tidal CO2 detector.
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
Umpierrez, Guillermo E., Mary Beth Murphy, and Abbas E. Kitabchi. "Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome." Diabetes Spectrum15.1 (2002): 28-36.
ARIEFF, ALLEN I., and HUGH J. CARROLL. "Nonketotic hyperosmolar coma with hyperglycemia: clinical features, pathophysiology, renal function, acid-base balance, plasma-cerebrospinal fluid equilibria and the effects of theraphy in 37 cases." Medicine 51.2 (1972): 73-94.
Gerich, John E., Malcolm M. Martin, and Lillian Recant. "Clinical and metabolic characteristics of hyperosmolar nonketotic coma." Diabetes 20.4 (1971): 228-238.
Kitabchi, Abbas E., et al. "Hyperglycemic crises in adult patients with diabetes." Diabetes care 32.7 (2009): 1335-1343.
Kitabchi, Abbas E., et al. "Hyperglycemic crises in adult patients with diabetes a consensus statement from the American Diabetes Association." Diabetes care 29.12 (2006): 2739-2748.
Ellis, E. N. "Concepts of fluid therapy in diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic coma." Pediatric clinics of North America 37.2 (1990): 313-321.
Pinies, J. A., et al. "Course and prognosis of 132 patients with diabetic non ketotic hyperosmolar state." Diabete & metabolisme 20.1 (1993): 43-48.