Bilateral Tension Pneumothorax: Harder To Diagnose

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
  • tachycardia
  • hypotension

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

PostObstructive Pulmonary Edema

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.

The Case

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

Airway Emergency: Start With The Basics of Airway Management

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

Finding PEEP In a Bottle (of Water): Thinking Outside The Box

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

Intubation With Airway Bleeding and Massive Emesis

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

To Extubate, Or Not to Extubate, That Is The Question

Assessing extubation criteria, and then deciding when to extubate a patient safely can sometimes be a difficult decision.

Extubation Criteria

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 From Endotracheal Tube Compression

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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.

Case Description

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.

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