Intubation Modalities

Which intubation modality should I choose?

There are more options to intubate a patient besides our standard RSI techniques. I’ll be giving a brief overview of some other options below & an excellent flowchart from WJEM. Since this is a POTD, I will not be going in depth into each modality. However, I’ll try and include major indications & pitfalls when going through them.

Delayed Sequence Intubation (DSI): Primarily used in patients who are preventing you from oxygenating them (i.e. pulling off their bipap, agitated etc…). This is basically procedural sedation where the “procedure” is preoxygenation. 

Begin by giving a dissociative dose of IV Ketamine (1-2 mg/kg) and once the patient is properly sedated, preoxygenate them as you wish. Ketamine usually preserves their respiratory drive, but you may need to step in and intubate earlier than you anticipate if the patient were to experience respiratory depression. When the patient is adequately preoxygenated, you can give the paralytic and intubate the patient as you normally would. 

Sometimes, just forcing the patient to tolerate Bipap without interruption may result in the patient’s respiratory status improving and avoiding intubation. 

Ketamine Only Breathing Intubation (KOBI): KOBI is a great choice in physiologically challenging intubations where patients cannot tolerate a moment of apnea such severe acidosis. 

Begin by giving a dissociative dose of IV Ketamine. The patient will then be sedated, but still breathing. Then proceed with your intubation modality of choice. Beware, the patient may be a little rigid, have a higher risk of vomiting, and the vocal cords will still be moving. Either the vocal cords can be “timed” or a paralytic given shortly before passing the endotracheal tube. Even if a paralytic is not used, it should be readily available incase of complications such as jaw rigidity. 

Awake Intubation: Awake intubations are the ideal choice for cooperative patients that may be difficult intubations, but the intubation is less urgent. The advantage lies in that it is incredibly safe (the patient is breathing the whole time) and the procedure can be aborted if the intubation cannot be completed. An example could be a patient with Ludwig’s angina, where the loss of airway reflexes in RSI could lead to dire consequences if the patient is unable to be intubated. It would likely be difficult to oxygenate & ventilate a patient with Ludwig's angina, especially with all the soft tissue collapse after induction & paralysis in RSI, leading to disastrous consequences. 

Begin by drying out the oropharynx (gauze, glyopyrrolate). Then, the goal will be to topicalize extensively. 4% Nebulized lidocaine should be used. Atomized lidocaine should also be given via the nose and mouth (usually in awake intubations, nasotracheal intubation via fiberoptic bronchoscope is better tolerated than orotracheal intubation). Lastly, the patient can also gargle viscous lidocaine. The patient can also be given anxiolysis (such as versed) and may need soft restraints depending on the clinical scenario. Proceed with either orotracheal or nasotracheal intubation. Once you have passed the cords, the patient can be fully sedated since the airway is then secured. 

https://emcrit.org/dsi/

https://emupdates.com/kobi/

Merelman, A. H, Perlmutter, M. C, & Strayer, R. J. (2019). Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 20(3). http://dx.doi.org/10.5811/westjem.2019.4.42753 Retrieved from https://escholarship.org/uc/item/4b27s3ks

https://www.emdocs.net/awake-endotracheal-intubation/

POTD: The Ingested Coin

This POTD is inspired by a common occurrence in the pediatric ED and a question that routinely shows up on board questions.

History: Mom and Dad are spring cleaning the apartment when 1 year old Freddy Boy starts having sporadic episodes of gagging or choking, and has vomited once. Parents report an episode where he looked like he was breathing faster and almost looked like he was struggling to catch his breath, which has since resolved. Mom and Dad panic and bring F.B. to your ED. Physical exam reveals a happy looking kid, vitals WNL, and a benign exam. Nothing in the back of the throat. Normal breath sounds BL. 

As their provider, high on your differential is foreign body ingestion, and you begin your workup.

Background: Children frequently swallow foreign bodies, with coins being the most common. Other objects, such as fish or chicken bones, buttons, marbles, and the dreaded button battery are common (for adults, food boluses are most common, followed by fish bones, coins, fruit pits, pins, and dentures). A patient who has ingested a FB raises the concern- where is the coin? Is it in the esophagus, or the trachea? Has it already been swallowed and now in the stomach? What was the FB? Oftentimes the history can be suspicious for FB ingestion but the point (or object) of ingestion is often not witnessed. 

Whether the coin/FB be in the esophagus or the airway can produce similar symptoms. Patients can be vomiting, have episodes of gagging and choking, stridor, complaining of chest pain, pain in the neck, throat, or upper back, drooling, and an inability to eat.

A lot of those symptoms are fighting words- they're usually how you describe a patient in danger of respiratory distress, and thus the patient with FB ingestion must be assessed with ABCs in mind on initial and repeat assessments.

Imaging:

The most important next step on evaluation for ingestion of moderate to high risk ingestion is to obtain imaging. Obtain a CXR AP and lateral; additionally, a babygram xray can include the chest and abdomen, which can pick up a coin that may have already passed through the esophageal sphincter and is likely on it's way out.

Back to our case. The child has an xray depicting:

https://prod-images-static.radiopaedia.org/images/219249/4b44984b51f84022153d6f2572b60f_jumbo.jpg

This is an example of the coin being in the esophagus. On AP imaging, coins in the esophagus show their face, while objects stuck in the trachea will usually be visible only by its edge. Obtaining a lateral view can often times help you visualize the trachea; a coin stuck in the trachea on lateral view will show you its face.

https://img.grepmed.com/uploads/5385/peds-trachea-coins-esophagus-chestxray-original.jpeg

In the esophagus, objects are most likely to get stuck at the cricopharyngeus muscle (about 75% of the time), at the level of the aortic arch, and the lower esophageal sphincter.

What to do depends on the object swallowed and where it is located. For esophageal FB, if the object is sharp, a single high powered magnet or several magnets, a disk battery stuck in the esophagus, if airway compromise is present or imminent due to mass effect on the trachea, evidence of perforation, unable to manage secretions, or if the point of ingestion is possible to be >24 hours, emergent/urgent endoscopy is needed.

For esophageal objects that don't have these characteristics, definitive intervention such as endoscopy can be delayed up tot 24 hours to allow a chance for the object to pass spontaneously. If past the lower esophageal junction, objects are very likely to pass through the GI tract on their own. If warranted, objects can be be monitored with serial xrays to follow the object on its way out. These benign objects can be expectantly managed, and the asymptomatic patient can be sent with follow up with PMD/GI.

For tracheal objects, such as this coin, in a patient without complete airway obstruction/on the verge of airway compromise, you can provide supplemental O2 if needed, have the parents calm the child if possible, and allow the patient to assume a position of comfort. These patients are likely to need bronchoscopy to remove, and it is important to get your ENT and possibly anesthesia friends involved in the case.

Best,

SD

Sources:

https://www.grepmed.com/images/5385/peds-trachea-coins-esophagus-chestxray

https://radiopaedia.org/cases/ingested-foreign-body-coin-in-oesophagus-3

https://learningradiology.com/archives2008/COW%20313-Coin%20in%20esophagus/coinesophcorrect.htm

https://www.ncbi.nlm.nih.gov/books/NBK430915/

https://www.uptodate.com/contents/foreign-bodies-of-the-esophagus-and-gastrointestinal-tract-in-children

POTD: Retropharyngeal Abscess

Retropharyngeal Abscess

What is it?

• Polymicrobial abscess in space between posterior pharyngeal wall and prevertebral fascia

• Adults: Usually due to direct extension of local infection (ex. ludwig's angina, pharyngitis, dental abscess etc.)

• Peds: Usually due to suppurative changes in local lymph nodes from an infection in the head or neck

• Can also be caused from trauma- falling with pencil in mouth

Presentation:

• Patients may prefer to lay down to prevent abscess from collapsing the airway. If your suspicion is high enough, don't sit these patients up!

• Patients will complain most commonly of: sore throat, fever, torticollis, dysphagia

• In late stages will develop airway involvement (looks for stritor, change in phonation, drooling, neck stiffness, tripoding, SOB)

Diagnosis:

• CT Neck with IV contrast

• On CT you will see loss of definition between the anatomic spaces in the neck, stranding in the subcutaneous tissues, tissue enhancement, and frank abscess formation, the location of the findings indicates whether it is a parapharyngeal or retropharyngeal space infection

• You can get a soft tissue neck x-ray, but if your suspicion is still high and the x-rays are equivocal, you should still get a CT

• MRI is useful for assessing the extent of soft tissue involvement and for delineating vascular complications

Management:

• Get Anesthesia/ ENT involved early if there is any degree of upper airway obstruction!

• These signs include: neck extension/head in sniffing position, stritor, change in phonation, drooling, neck stiffness, tripoding, SOB,  retractions

• Coordinate with Anesthesia/ ENT to secure an airway (Tracheostomy in the OR or fiberoptic intubation should be considered)

• If there is no airway compromise, consult ENT because many of these patients require I&D/ needle aspiration in the OR

• Retropharyngeal abscess <2.5cm without airway compromise can potentially receive a trial of empiric IV abx for 24-48 hours without drainage  

•  Antibiotics (Covering: GAS, Staph aureus, respiratory anaerobes, +/-MRSA)  options include: Ampicillin/Sulbactam 3g IV  or Clindamycin 600-900mg IV or Cefoxitin 2gm IV  

• Admit