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AnginoEdema. Really? You better look at this patient NOW!!!!!!!

April 19, 2016

How my limited training with simulation was not enough the day I failed to successfully intubate via the nose, this patient with the worse Angioedema I have ever seen on a patient. 

Blood trickled from both sides of her mouth. The swelling was that severe that the tongue pressed into her upper and lower teeth. 

Wowza.....

 

Saw this patient and her tongue and initiated what I had thought was going to be the easier path, nasal intubation. I had my surgical airway kit ready.

But Failed with ketamine only sedation/analgesia. Gave pain dosing of 20mg ivp with patient premedicated with atropine 0.5mg x2 since we dont have glycopyrrolate. 

I failed getting around the edematous aryiepiglottic folds. and when I got close she gagged and saliva would cover the distal tip of the fiberoptic scope that was lent to us from the ICU fellow.

He had never been called to lend the scope in the ED. I made a mistake and told him I didnt need suctioning capability/attachments. My error.

 

2 anesthesiologist failed with their fiberoptic scope. 

one of them even tried to pry around the limited mouth space of the patient with a glidescope but her gag reflex was too strong.

Luckily the one who does bronchoscopy a lot as a pulmoanry/icu fellow, got it in. 

The patient was never paralyzed nor ever desated. Mild tachycardia on the monitor. 

She was scared, Her husband was scared. I was scared but couldnt show it. 

My heart raced. Never raced when I drink my Monster Energy drink. But that patient and this case made it race so hard and face. I had to take deep breaths with my surgical mask on. 

I had my surgical cric kit ready should she unexpectedly decompensate.

 

The case humbled me. I need more practice with the intubating scope. And always get a scope with suctioning. 

 

 

 

 

Teaching point:

I had to be happy for the patient's safety and good outcomes even if you had to ask for help.

Either get better at fiberoptic scope

Or commit to the surgical airway sooner

Or master intubating with an intubating LMA with using RSA to get access the the glottic opening before using the intubating fiberoptic scope thru the LMA's lumen. 

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