At two o'clock in the morning, a hurried phone rang in the operating room, and the 15th floor cerebral infarction patient was urgently intubated. The anesthesiologist who received the call did not dare to delay at all, picked up the tracheal intubation equipment, and rushed to the department urgently. Understand the basic situation of the patient with the clinician and explain the risks of intubation to the family. After the family agrees, the scene is cleaned up, the family avoids it, and the tracheal intubation is urgent.
However, unlike usual, after the laryngoscope was inserted, the glottis was not visible on the video laryngoscope screen, but a white tablet the size of a corn kernel was seen stuck in the spoon-shaped epiglottis on the right side of the glottis. The patient had cerebral infarction, dysphagia, and no intubation forceps equipment due to the limited conditions in the ward. After trying to take it with chopsticks, the small pill was still not removed after the suction tube was suctioned. Seeing that the patient's blood oxygen could not be maintained, and the spontaneous breathing was weak, he could only intubate the trachea first and then try to take the foreign body. However, if the tablet enters the trachea by mistake, an emergency airway can be formed, and the tracheal foreign body needs to be removed, so the pressure is greater.
Time is running out, and the patient's head is slightly tilted to the right by 20 degrees to prevent the pill from sliding into the airway. Placement of a video laryngoscope shows that the patient's larynx is high, and the glottis cannot be visualized, and can only be slid along the epiglottis. After confirming that the endotracheal tube was in the correct position, I tried to use the tracheal tube core to slowly hook it outward, and finally with the assistance of the medical staff in the ward, the tablet was successfully removed, and in order to prevent residues, I attracted the oral cavity twice, and finally breathed a sigh of relief when I looked at the blood oxygen saturation that no longer dropped.
According to the author's information, the probability of encountering a difficult airway in emergency intubation outside the operating room is as high as 9~12%. Multiple airway adverse events have been reported in many internationally renowned hospitals, and all of them occur outside the operating room. Intubation outside the operating room is more challenging for anesthesiologists, both in terms of technical level and psychological quality, but not 100% of patients can complete intubation in the first time.
If there is a difficult airway, the formally trained anesthesiologist is unable to intubate properly after 3 attempts, the anesthesiologist should be replaced, the intubation should be abandoned after 4 intubations, the intubation failure should be announced in time, and the mask or laryngeal mask ventilation should be changed.
If ventilation still fails, cricothyroid puncture or immediate tracheotomy can be performed, but the family should be informed of the process and outcome in a timely manner, and informed consent should be obtained.
The whole treatment process requires the cooperation of clinicians and anesthesiologists, timely communication and consultation with relevant departments, and the intubation is the last straw for patients to save their lives.
Yan Weina, Department of Anesthesiology, Zunhua People's Hospital
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