Tension pneumothorax is a life-threatening emergency. We all know the signs of tension pneumothorax:
unilateral breath sounds (breath sounds absent on affected side),
thorax may be hyperresonant,
jugular venous distention,
tracheal deviation to the opposite side,
maximum heart sounds shifted to the opposite side, and often
However diagnosis is more difficult if the patient is suffering from bilateral tension pneumothoraces. We think about bilateral tension pneumothorax occurring with trauma cases. Yet the three cases I’ve seen in my career were complications of intubation and emergency airway management. Continue reading →
Patients with postobstructive pulmonary edema (or P.O.P.E.) develop sudden, unexpected and potentially life-threatening pulmonary edema after relief of airway obstruction. It can be mild or severe. My first experience with it was in 1983.
In 1983, we didn’t have pulse oximetry, end-tidal carbon dioxide monitoring or even automated blood pressure cuffs. The patient was a healthy 6’3” tall and 250 lbs , 20 year old man. All muscle and clearly in great shape. He had just had knee surgery under general anesthesia and was on the verge of waking up.
He was coughing vigorously on the endotracheal tube. Four people held him down. My resident, fearful he night hurt himself or the team, extubated him while he was still coughing and before he was following commands. Unfortunately the patient was still in stage 2, when the airway reflexes are hyperdynamic.
Within seconds the patient went into laryngospasm, intense spasmodic closure of the vocal cords and other laryngeal muscles. There followed several minutes of struggling to re-establish an open airway. Finally the spasm broke with the use of positive pressure and the patient awoke.
However the mood in the room quickly turned from relief to concern. Our patient started to panic, claiming that he couldn’t breathe. His color was poor. He was wheezing badly, with pink frothy sputum bubbling out of his mouth. He was awake enough to communicate with us but so panicked that he started to fight the team of caregivers. Continue reading →
We have just finished another round of Critical Event Training for my hospital’s Anesthesia and OR staff. One of the scenarios we ran was how to manage a failed airway emergency: the dreaded “can’t intubate-can’t ventilate” airway emergency scenario.
As an instructor, it’s important for me to set the stage realistically. The more real the scenario, the more the providers will learn and be able to apply the information should they ever find themselves in a comparable situation. I must observe as the trainees respond to the emergency, and then help the trainees self-analyze what went well — or not so well — during the scenario. Of course, discussion of how things went during a training scenario always leads to sharing of examples from past real life scenarios. And after 37 years of practice I’ve had a lot of sharable experiences.
One past case we discussed is particularly appropriate for those students around the country who are just beginning to learn airway management because the solution rested in basic airway management techniques. This case, involving an intubation in an ICU patient that turned into a “can’t intubate/can’t ventilate” emergency demonstrates how returning to the basics of airway management can sometimes be the way to save your patient from harm. All illustrations from Anyone Can Intubate 5th Edition. Continue reading →
I recently visited Honduras with a Head and Neck surgical team where we had a close call with a potential airway obstruction due to a blood clot. The case illustrates how a provider should never make assumptions, because if those assumptions are wrong, you can endanger your patient.
After a long day in the OR, while we were packing up to leave, a nurse from the ward ran in and said that one of the patient’s who had had a septoplasty that day for chronic sinusitis was bleeding. I immediately started setting up the OR again while our surgeon went over to the ward. Continue reading →
As you read this I am flying to Honduras with International Relief Team on a head and neck surgery medical mission. I will attempt to post mission updates from the hospital compound, pending internet connections. Participating in a medical mission to the developing world is never easy.
Medical personnel trained in a high tech environment take for granted the complex monitoring devices, multiple choices of drugs, and plentiful support peronnel which simplify our job. When medical volunteers travel to the developing world they are often unprepared for the potential hazards produced by outdated technology, unfamiliar and sometimes poorly maintained equipment, poor sanitation, limited supplies, and a malnourished, often poorly educated population.
Let me give you an example of one rather exciting case from early in my volunteer experience. Continue reading →
Our Healing Little HeroesFoundation founder dressed as Darth Vader at Ronald McDonald House, San Diego
Last weekend I spent time with the charity group Healing Little Heroes at the San Diego Rady’s Children’s Hospital, and Ronald McDonald House. The mission of Healing Little Heroes Foundation is to help pediatric patients in hospitals and outpatient settings to heal emotionally and mentally by appearing as Superheroes. My good friend, and general surgeon, Justin Wu, dressed below as Darth Vader, set up the Foundation.
On this day we arrived in full Star Wars costumes to entertain the kids and their families. I’m dressed as Queen Amidala. Which brings me to the topic of today’s conversation. Can hairstyle impact your intubation or even your anesthetic management? The answer is yes. There is no question that if Queen Amidala needed emergency intubation, that her hairstyle would get in the way. Continue reading →
During intubation, any liquid in the mouth that obscures the view of larynx not only hinders visualization, it risks aspiration. We’re used to being able to rapidly suction the mouth clear or secretions, blood, or vomit and then have a clear view of the larynx. But sometimes, either because of continued profuse airway bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate? Here I describe two cases, one involving blood and the other massive emesis, that required intubation through a large puddle of fluid. I offer tips and tricks to assist you in your future emergency management. Continue reading →
There is nothing quite as scary as being in the middle of administering an anesthetic and having your anesthesia machine fail. In my 36 years of anesthesia practice I’ve had this happen to me a few times. Knowing how to quickly troubleshoot your machine, and knowing how to protect your patient are important, potentially life-saving skills. It helps to have thought through the steps to rescue the situation before it happens to you.
Here I describe how I learned this lesson the hard way on a volunteer medical mission to rural Honduras. When my machine failed, I was poorly prepared and this forced crisis management that I could easily have avoided with a little forethought and preparation. Continue reading →
Although the initial FDA warnings about potentially fatal overdose from codeine in children were released in 2012, I’m recently discovered that a few of my surgeon and nursing colleagues were still unaware of the potential risks. Therefore I thought it might be helpful to bring up the topic so people can remind their own colleagues of the risks of codeine in children.
Codeine must be used with extreme caution, if at all, in young children or pregnant women because of variants in the enzymes some patient’s use to metabolize the drug. Continue reading →
When we place anything in the mouth, be it an endotracheal tube, oral airway or LMA, we are typically extremely careful to protect the teeth. We take care to avoid cutting the lips with the teeth. But we often take the safety of the tongue for granted. I recently recognized a potential problem while using an LMA supreme that could have caused tongue ischemia if not corrected. Let we show you what happened so you can be on guard with your own patients. Continue reading →
Assessing extubation criteria, and then deciding when to extubate a patient safely can sometimes be a difficult decision.
We all know the common extubation criteria:
recovery of airway reflexes and response to command;
inspiratory capacity of at least 15 ml/kg;
no hypoxia, hypercarbia, or major acid/base imbalance;
no cardiopulmonary instability;
signs of intact muscle power;
absence of retraction during spontaneous respiration;
absence of a distended stomach.
In other words, you want your patient to be stable, able to breathe without help, and able to protect the airway.
However, sometimes the decision is not so easy. Here I describe a case of a patient who met some but not all of the criteria for extubation. The reason turned out to be due to a rare complication: plugging of the endotracheal tube. However, getting to that solution required working through the extubation algorithm. Continue reading →
Tongue necrosis is fortunately an extremely rare complication of endotracheal intubation, but the injury can be devastating. It’s important to recognize the patients at risk and to take precautions when securing an endotracheal tube to decrease the risk of injury.
I saw this injury myself many years ago. I was called to the ICU to evaluate a patient for postoperative tongue pain. The patient was an otherwise healthy 41 year old who had undergone cervical spine decompression for tumor two days before. The patient had been in the prone, head flexed position in tongs during a surgery that had lasted about 7 hours. About 2 liters of crystalloid had been given and blood loss was less than 200 ml. Surgery had been successful and the patient had been extubated at the end of the case neurologically intact.
When the patient started talking to me, speech was terribly slurred. Almost the entire right side of the tongue was a pale brown and gray color, firm, and markedly edematous with an ulceration. Tongue necrosis was diagnosed. I don’t have a picture for this patient, but this photo, taken from an excellent review of tongue necrosis, is similar.
Photo of tongue necrosis from Laryngoscope. 2010 July; 120(7): 1345–1349.
During the case, since neurostimulation was to be used to monitor spinal cord function, two fairly large, soft bite blocks made of rolled gauze had been placed to prevent the patient from chewing the tongue or mouth when stimulated. At the end of the case, the anesthesia team noted that the tongue looked a little swollen and that the tube had left an imprint over the back of the tongue. Continue reading →
I saw a potential aspiration hazard in the OR today. How many times a day do we routinely peel plastic wrappers off of airway equipment? If I’m at the surgicenter, I might need 7 face masks, a variety of LMAs and endotracheal tubes and an oral airway or two.
Take a look at the typical plastic wrapped mask here in this photo. We unwrap these sorts of objects dozens of times a day.
Typical plastic wrapped disposable mask.
Here is the same mask unwrapped. Do you see the hazard I found?
Same unwrapped mask with an almost invisible aspiration hazard inside.
Here it is, a tiny piece of torn plastic that was stuck to the inside of the mask. It’s almost invisible unless you look for it.
Aspiration hazard: a bit of plastic wrap stuck inside the mask
Look back at the wrapped mask. Do you see it now?
Arrow points at aspiration hazard inside the mask
Aspirating something like this could have serious consequences. In anesthesia, or any field of medicine, the devil is in the details. You cannot be too compulsive about safety. Check and recheck everything. Every little bit counts.
My hospital routinely runs mock codes in a variety of settings to make sure that all providers can quickly and efficiently act as a team if the worst happens. This includes our operating rooms. Cardiac arrest under anesthesia in the OR is fortunately rare. The total number of OR procedures performed in the US last year was 51.4 million. The incidence of intraoperative cardiac arrest has been quoted as less than 0.1%. However, a small percentage of a large number is still a fairly significant number. Getting prepared for rare events is often more challenging than preparing for regular events. When a rare event happens the shock and fear induced by the event can erase protocol from the most prepared mind. Let me share some of the things that I’ve learned over almost 36 years of OR emergencies. Continue reading →