What Difficult Airways by Dr. Jonathan St. George means to me?




3 situations make airway management difficult.

Delineated clearly by the recent Tweet by my colleague at NYP-Cornell 


of the 3 following scenarios

1. Situationally difficult?

Outside of the ED. Found the patient in the bathroom. The patient is seated on the toilet. The patient is found down in an elevator as its rising or going down. Found on the floor supine or prone or lateral decubitus positions. Found with lack of tools like Bag Valve Mask, supraglottic device, direct laryngoscopy, video laryngoscopy, or even scalpel/bougie/endotracheal tube. 


2. Anatomically difficult?

You have no control of the patient's glottic... opening being more anterior than usual. Tongue being very large. The prior infection/inflammation/thermal injury/allergic reaction extent that the patient came in with was out of your control before they reached your care. The prior radiation therapy, or congenital defect or acquired distortion by prior surgery/recent trauma/or growth by a Tumor was not in your control before the patient reached you. 


3. Physiologically difficult?

Hypoxic. From pneumonia, ARDS, decompensated chf, aspiration, pneumothorax, respiratory failure from tiring out. Pre-oxygenate with high flow nasal cannula, plus 15 liters per minute NonReBreather mask, or Pre-oxygenate with what you have with Bipap/NiV or if you only have a bag mask for ventilation, add Peep Valve and Bag up the apneic patient. 



From DKA, Hypercarbia, Salicylate toxicity, Alcohol toxicity, Lactic acidosis.

Be hesitant to paralyze this patient who is trying to regulate his pH status by breathing fast. Don't take it away. Ignorance doesn't forgive you the cardiac arrest that occurs after paralysis of a patient who likely was suffering from severe acidosis and you made it worse with RSI/prolonged apnea period following rsi/delayed intubation from failed intubation. Or first pass success and then erroneous ventilator settings that ensure a quick iatrogenic death. 



Regardless of the etiology of the Shock, i.e. anaphylaxis, hemorrhagic, obstructive, cardiogenic, neurogenic. Fix the problem, or address it with a bolus of fluid, iv pressors, treat the pericardial tamponade, or tension pneumothorax, or treat the p.e. or massive MI with lytics. 


Don't address any of the 3 and the patient will be ensured to suffer complications. 

Acidosis can only get worse.

Hypotension can only get worse.

Hypoxia can only get worse. 

Or 2 of the 3, or even worse, all the above at once being suffered by the patient.

Or some combination? Your patient will suffer end organ injury, perhaps with PEA, asystole or cardiac arrest. 







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