P015: IS RIGHT ALWAYS RIGHT?
Catalina Carvajal, DO, Jonah Zisquit, MD, Nicholas B Nedeff, MD, Sharlene Lobo, MD; Kendall Regional Medical Center
Introduction: Thermal injuries may present as overt dermal burns as well as an occult inhalational injury, or a combination of both that could present hours after exposure. A 77-year-old obese male presented 24 hours post inhalational injury from tortilla smoke. On admission, patient was found to have stable vital signs without signs of external or mucosal injury. Patient has a medical history significant for hypertension, chronic obstructive pulmonary disease, and heavy smoking. Patient was placed in the intensive care unit (ICU) for observation.
Methods: Following 24 hours in the ICU, a suspected 48 hours following exposure to smoke, the patient began to complain of shortness of breath. He was subsequently placed on a non-rebreather mask (NRFM) to assist in oxygenation and Anesthesia was called to secure the airway. On exam, patient was sitting up in bed extremely agitated and uncooperative for Mallampati exam. He was saturating 100% on 15 liters of oxygen via a NRFM and swelling was noted around his neck. The patient required intubation and he was not stable enough to move to the operating room. The surgical team was in the room to assist in the event of a surgical airway as well as the respiratory therapist and nurse. The standard emergency airway tray was prepared with the addition of the glidescope, suction, Ambu bag, end-tidal indicator, and oxygen source. Induction was made with propofol alone and without the use of any neuromuscular blocking agent.
Results: The initial attempt was performed with a MAC 4 blade in which a grade 4 view was obtained, and only soft tissue was visible. A second attempt was performed using video laryngoscopy in which the epiglottis was identified with a small potential glottic opening seen in the upper left hand of the screen. At this point a call for help was requested to additional anesthesia providers. Patient was able to be ventilated in between each attempt with an oropharyngeal airway and 2-handed face masking. Third attempt with a glidescope with a different provider obtained a similar view with attempted endotracheal tube placement without ETCO2 color change. A call was placed to bring in the flexible fiberoptic scope (FOB). On the fourth attempt, the FOB was unable to pass through the glottic opening. On fifth attempt, the FOB with the glidescope blade to assist in guiding the scope and it was still unable to pass beyond the epiglottis. Lastly, on the sixth attempt, the FOB was inserted on the LEFT of the glidescope blade and successful endotracheal intubation was obtained.
Discussion/Conclusion: Patients involved in an explosion or smoke affected environment should be examined for possible thermal inhalational injury. Signs and symptoms may range and present themselves hours after the incidence when airway edema worsens. There should be a high index of suspicion for securing the airway in burn patients. Additionally, when confronted with a difficult airway it is critical to ensure the ability to ventilate and to have accessibility to an emergency airway should there be a can’t intubate can’t ventilate situation.