DP10: THIRD TRACH'S A CHARM: MANAGEMENT OF FAILED TRACHEOSTOMY IN A PRIOR DIFFICULT AIRWAY
Kade E Eppich, MD; Amanda Frantz, MD; Letitia E Bible, MD; Ryan Parker, MD, PhD
University of Florida
Background: The overnight anesthesiology team was called to the intensive care unit (ICU) to emergently assist in airway management. A trauma patient with a known difficult airway was status post a motorcycle crash with multiple facial fractures and severe TBI. He was post-operative day 1 from a tracheostomy and a few hours status post an emergent tracheostomy revision for ventilation failure in his second tracheostomy. He now presented with herniation of his second tracheostomy and acute desaturation. On arrival to the intensive care unit, the patient’s oxygen saturation was 90% with assisted ventilation via an Ambu bag and the trauma surgeon’s finger inserted into the bleeding stoma. The anesthesiology team was called to discuss airway management.
Methods: After a discussion with the trauma team about the best location to secure the airway, the decision was made to attempt airway management in the ICU. A spontaneously breathing video laryngoscopy technique utilizing ketamine and a McGrath X3 blade was attempted. Despite visualization of the endotracheal tube (ETT) passing through the vocal cords, the initial attempt resulted in desaturation and no end tidal CO2. The ETT was removed after it was presumed to have exited the trachea via the stoma and entered a false passage. On the second attempt, the ETT was passed through the vocal cords and then digitally guided into the trachea via the stoma. Oxygen saturations improved, and end tidal CO2 was present. After securing the airway, the patient was sedated with propofol and transferred to the operating room for his third (and final) tracheostomy.
Discussion: Here, we present an emergent difficult airway with limited rescue techniques available. A traditional intubation approach was viewed as risky given the patient’s status as a known difficult airway and the presence of unstable facial fractures that made the use of paralytics risky. Likewise, the patient’s severe TBI and uncooperative nature prevented an awake fiberoptic approach of the known difficult airway. More concerning, however, was the existence of a bleeding tracheal stoma that eliminated the option emergency cricothyroidotomy. Given these circumstances, the decision was made to attempt airway management in the ICU with a spontaneously ventilating video laryngoscopy approach. While the first attempt failed due to the presence of a false passage near the stoma, the use of spontaneous ventilation and digital guidance beyond the stoma safely secured the airway for his third and final tracheostomy revision.