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Combined Otolaryngology-Anesthesia-Emergency Medicine Difficult Airway Conference

Combined Otolaryngology-Anesthesia-Emergency Medicine Difficult Airway Conference. Dowling Amphitheater February 12, 2007. Case. A 60 year old man, (80 kg, 5’8”) suffered a hemorrhagic stroke shortly after a full meal.

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Combined Otolaryngology-Anesthesia-Emergency Medicine Difficult Airway Conference

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  1. Combined Otolaryngology-Anesthesia-Emergency Medicine Difficult Airway Conference Dowling Amphitheater February 12, 2007

  2. Case A 60 year old man, (80 kg, 5’8”) suffered a hemorrhagic stroke shortly after a full meal. He was taken to a community hospital unconscious and with breathing difficulty. In the ER, endotracheal intubation with direct laryngoscopy was attempted several times unsuccessfully. A laryngeal mask airway (LMA) was inserted and somewhat adequate ventilation was achieved. The patient was transferred to Boston Medical Center with the LMA in place, unconscious.

  3. Physical Exam • Unresponsive (GCS < 6) but not paralyzed • Hemodynamically stable • Husky, short neck • Mouth opening – difficult to evaluate • LMA #4 in place • Full dentition • Distended tympanic epigastrium • Distant breath sounds – ventilated with bag-valve • Hgb O2 Sat: 98%

  4. Challenge How should we manage the airway?

  5. Considerations • Fiberoptic assessment of larynx through LMA? • How long can he remain apneic? • Do we sit the patient up? • Should neuromuscular blocking agents be used? • Should a nerve stimulator be used? • Insert NGT? • Remove LMA? • Attempt direct laryngoscopy again? • Intubate through LMA? • Cricoid pressure? • Surgical airway? • Control hemodynamics?

  6. Conventional LMA

  7. LMA is a conduit

  8. Fiberoptic Exam Through LMA

  9. Intubating LMA

  10. Intubating LMA

  11. ProSeal LMA

  12. Combitube

  13. Combitube CT of the cervical spine showing an over-inflated distal balloon of the combitube (solid arrow), placed in the esophagus, severely compressing and narrowing the adjacent trachea (dashed arrow). From:   Portereiko: J Trauma, Volume 60(2).February 2006.426-427

  14. King L-T

  15. Other Devices

  16. Cutting the LMA Anesth Analg 2003;97:299-300

  17. Considerations • Fiberoptic assessment of larynx through LMA? • How long can he remain apneic? • Do we sit the patient up? • Should neuromuscular blocking agents be used? • Should a nerve stimulator be used? • Insert NGT? • Remove LMA? • Attempt direct laryngoscopy again? • Intubate through LMA? • Cricoid pressure? • Surgical airway? • Control hemodynamics?

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