2024 FSA Podium and Poster Abstracts

P083: OPEN TRACHEOSTOMY WITH VV-ECMO IN A SUPER OBESE PATIENT
Emily Chung, DO; Omar Chahine, DO; Hani Murad, MD; Kalina Nedeff, MD; Victor Iturbides, MD; Kendall Regional Medical Center

Introduction: In the trauma bay, a 45-year-old female, with a medical history encompassing COPD, pulmonary embolism treated with apixaban, hypertension, obesity class V, and diabetes mellitus type II, arrived as a level I trauma victim after a high-speed automobile collision with a tree. Following the incident, the patient underwent nasotracheal intubation due to a lingual hematoma, later replaced with an endotracheal tube.

Methods: Throughout her hospitalization, the patient faced challenges, including two unsuccessful tracheostomy attempts. The first, a percutaneous tracheostomy, was halted due to hypoxic cardiac arrest, requiring CPR and resuscitation. A subsequent open tracheostomy was also interrupted by hypoxic cardiac arrest, with successful resuscitation achieved after CPR. Subsequently, a 6.5 armored endotracheal tube was inserted into the tracheostomy site by the surgery team, confirmed through bronchoscopy, end-tidal CO2, and tidal volume assessments.

In preparation for the next attempt, the surgery team consulted cardiothoracic surgeons for veno-venous extracorporeal membrane oxygenation (ECMO) cannulation. The right internal jugular vein was accessed under ultrasound guidance, and a 32Fr Crescent dual lumen ECMO cannula was inserted, verified via fluoroscopy. A midline incision allowed the placement of the tracheostomy, connected to the ventilator, and sutured into place.

Results: The procedure transpired without complications, and the patient remained on ECMO post-procedure. However, two days after decannulation, a code blue was initiated due to pulseless electrical activity (PEA). Despite five rounds of CPR and epinephrine administration, return of spontaneous circulation (ROSC) remained elusive. The family was informed, and chest compressions were ceased, marking the time of death.

Discussion/Conclusion: This case highlights the intricate challenges faced in managing the aftermath of a high-velocity automobile crash in a patient with a complex medical history. The recurrent hypoxic cardiac arrests emphasized the critical nature of airway compromise, evidenced by the unsuccessful tracheostomy attempts. Despite a seemingly uncomplicated ECMO intervention, the patient experienced an unfortunate post-decannulation event leading to an unsuccessful resuscitation.

The management of obese patients, as exemplified here, underscores the complexities and potential complications associated with airway management. Studies comparing tracheostomy complications in obese and "normal weight" patients reveal a 25% incidence in obese patients with an estimated 2% mortality. Individualized institutional protocols are suggested to mitigate complication rates in obese patients. This case prompts further consideration of tailored approaches and protocols for airway management in obese patients to enhance outcomes and reduce potential complications.