The Double Set-up

Hi all,

This is going to be a short but important POTD!

I wanted to write about an airway set up technique, colloquially termed “The Double Set Up” that the trauma and northside teams used yesterday during a level 1 trauma.

Without giving any secrets away for a case that will likely be an M&M in the future, for some situational background, the patient was getting progressively hypoxic with vomitus covering the entire airway. It was hard to get visualization of the airway using the Glidescope. The airway options were clear: either tube via DL or crich.

The team smartly employed the double set up technique to secure the airway. 

What does this term mean?

The double set up is when you have simultaneously set up for an orotracheal intubation and for a cricothyroidotomy. The EM/ anesthesia physician is at the head of the bed with the orotracheal airway equipment, while the surgeon is completely prepared for the crich with the scalpel in hand at the neck of the patient. The neck should already be prepped, and the landmarks should be identified.

When should we do the double set up?

Strayer has an amazing blog post about this (see below). Here are some indications where you might want to do the double set-up:

• An unstable maxillofacial trauma patient

• As a last ditch effort to secure the orotracheal tube after a failed attempt

• Rapidly desaturating patient with challenging anatomical features / cannot be successfully bagged

• Concern for an obstructed airway

If the intubator is ultimately unsuccessful, they indicate to the surgical airway physician to proceed. If the orotracheal intubator is successful, then the surgical airway physician can stop.

References:

• Check out Strayer’s excellent post on this: https://emupdates.com/the-emergency-department-double-setup/ 

• https://www.emed.theclinics.com/article/S0733-8627(17)30075-5/pdf 

• http://maryland.ccproject.com/wp-content/uploads/sites/8/2015/09/Leeuwenberg-2015-Airway-Management-of-the-Critically-Ill-Patient-Modifications-of-Traditional-Rapid-Sequence-Induction-and-Intubation.pdf
  

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