A 30yM is brought to your ED by EMS. He was out with friends at a local bar, and as per history obtained by EMS, he became somewhat aggressive and combative before possibly seizing and collapsing to the floor. Unfortunately, that’s the best history available as the pt’s friends high-tailed it from the scene as soon as the EMS crew arrived. Vitals were within normal limits on EMS arrival. There blood glucose level was normal. Pupils were smallish but reactive. GCS was 3. He smelled of ETOH and there was ?vomit on his lips.
This case was graciously shared with me by a colleague and it is an excellent opportunity for reflection on decisions made in airway management. As you read along this case, think to yourself if you would have done things similarly or differently – imagine yourself running this case. The focus here is not on the differential diagnosis but more so the decisions and outcomes in airway management. As per usual Chart Review protocol, details have been modified to protect confidentiality. This is a long one, so be patient as you read through the case.
On his arrival to the ED his exam is essentially unchanged. An oral airway is in situ and tolerated by the patient. There does not appear to be any material or pooled secretions in his mouth, but some brownish dried liquid is on his lips. He has a RR of about 14, with equal A/E bilat and when you remove the oxygen he still has an O2 sat of 99% on room air. Heart rate and BP are normal. GCS still 3 and pupils unchanged. No obvious signs of head trauma. No needle track marks and remainder of exam is unremarkable. When RT arrives on scene, they don’t see chest rise so they bag a few times and you say “wait, he’s breathing on his own!” You grumble to yourself. You find his cell phone but it is locked and you can’t browse the numbers. Fortunately, someone calls and you answer. The caller is reluctant to say anything about the pt or if they were together earlier that night. He hangs up. You grumble again.
Would you intubate this patient?
I think most of us would. GCS here) argues against use of GCS alone as an indicator for an ETT. However GCS alone is insufficient to decide. Although there are no pooled secretions or material in his airway, he seems far too comfortable with the oral airway that he certainly is at risk of aspirating. There are also signs that he may have vomited. He is saturating well on room air (blood gas would later show normal pCO2, and for completeness the remainder of labs were non-contributory). He is undifferentiated, however, and would likely need head imaging so intubation and sedation would help facilitate this test. (CT would be normal)
The decision was made to intubate. Now, at the hospital where this case was seen, the RT’s do a lot of intubations – both in ICU and the ED, and that is just the culture there. So RT was ready to intubate. The next question…
Would you do RSI? (ie do you paralyse the patient?)
Argument against: The patient has a GCS of 3, tolerating an oral airway. We have evidence his LOC is depressed enough to tolerate the procedure. RT said “we don’t need to paralyse.”
Argument for: RSI/paralysis gives the intubator the best look and highest success rate compared to pts who are not paralysed. Further, he may have vomited already so he is at risk of vomiting again – and therefore aspirating.
The decision is made to try direct laryngoscopy without RSI. He had no features to suggest a difficult airway (see LEMON law – here’s a nice video www.youtube.com/watch?v=TRKuCBOsp2o). The cords are visualized and then the patient gags and vomits. You sweat and curse to yourself. Quickly, he is turned on his side, suctioned aggressively and then repositioned.
Now the decision is made to do RSI. Rocuronium and a small amount of propofol are used, and the tube is passed easily after a little more suction. You confirm with ETCO2 and secure in place. Portable chest x-ray is ordered. However after a few squeezes of the bag, something isn’t right. The patient’s sats are in the low 80’s and there is unequal chest rise. You sweat some more.
The left side is moving and the right is not. So it’s not a right main stem intubation. Pneumothorax? Maybe. There was a fall and possible trauma to the chest. X-ray tech is outside the room, and they take their picture but it will be 2 minutes before you see it uploaded. So you run to get the ultrasound and ask the nurse for a 14G angiocath. As you stick the probe on the chest – no lung sliding. You try to switch to M-mode for your seashore sign but the machine is stalling on you. You sweat a lot. A lot.
Luckily the CXR is uploaded and you see the following:
That is a massive aspiration.
You are glad you didn’t put the needle in. But you panic a little the patient is still saturating in the low 80’s. Fortunately, internal medicine on call is an intensivist. You show him the x-ray and he calls for the fiberoptic bronchoscope. In the meantime, the patient is placed on his left side – this facilitates pulmonary circulation to favour the ventilated side and hopefully minimize the shunting to his junk-filled right lung.
Several minutes later, the bronch is here and copious amounts of semi-digested foodstuff are removed from his right lung. Sats are up. Chest rise is improved. A repeat x-ray shows the following:
The patient is taken to ICU and does well. In fact, he tried to extubate himself a few hours later but was kept sedated until the next day just to be safe. He left the next day, asymptomatic. The culprit of this journey: gamma-hydroxy-butyrate aka GHB aka “liquid G”.
I think we can all relate in some way or another to this case. With a case like this, there are multiple points in the management where things could have been different.
1) Decision to intubate: If we knew GHB was the culprit, you could argue intubation isn’t necessary. Many would argue that GHB-intoxicated patients do fine without airway management (article here) and in fact most of them wake up combative and yanking the tube, possibly causing worse trauma to the airway. Unfortunately, as was the case here many patients don’t come with a note that tells you what they took. I wouldn’t argue the decision to intubate, especially given that he probably already vomited once.
2) Bagging the patient: In a spontaneously breathing patient with normal numbers, don’t bag. This leads to insufflation of the stomach and increases risk of vomiting and aspiration. In this case, it was thought by the airway manager that there were no spontaneous efforts. Fair enough, honest mistake.
3) Deciding to intubate without RSI: As mentioned above, RSI significantly improves successful ET intubation. Multiple studies have demonstrated this, some of which are found below in the references/resources section. Contraindications to RSI would include an anticipated difficult airway in which awake intubation is preferred or a patient who is both unconscious and apneic, in which case you intubate without meds. Although the intent in this case was to intubate without administering unnecessary medications, the retrospectoscope has 20/20 vision, and we can probably agree that RSI was indicated here.
Fortunately this patient did well. This case is valuable because it has important lessons to take home.
What are your thoughts? Have you had similar experiences? Please comment or tweet back!
Emerg Med J. 2012 Dec 14. [Epub ahead of print]
What factors affect the success rate of the first attempt at endotracheal intubation in emergency departments?
Kim C, Kang HG, Lim TH, Choi BY, Shin YJ, Choi HJ.
Crit Care Med. Jun 2012;40(6):1808-1813.
Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications.
Wilcox SR, Bittner EA, Elmer J, Seigel TA, Nguyen NT, Dhillon A, et al.
J Emerg Med. 2009 Nov;37(4):451-5.
Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department.
Duncan R, Thakore S.