Clinical Case 143: a Perfect Airway Storm

This episode I reflect upon a really tough airway case.

I have asked a number of airway gurus from the FOAMed community to comment on the logistics and plan to manage this case.  Thanks to Tim Leeuwenburg, Rich Levitan, Roger Harris and Dr Richard Lewis of their contributions.

The patient

50 year old woman with a complicated medical history.

  • life long smoker & drinker
  • had large goitre resected 10 years ago with large anterior neck dissection
  • diagnosed with SCC of base tongue 3 years ago
  • large resection / reconstruction including mandibular graft
  • Radiation therapy to the anterior neck with lots of fixed scarring to neck.
  • Previous intubation (prior to XRT) was grade 3 and required a bougie for anterior larynx / hyper-angulated airway
  • Now quite cachexic but has no palliative intention

The situation

Presents to a remote ED (2000km from the next specialist ENT / Anaesthesia /ICU service.

Developed oral bleeding from fungating lesion on the posterior lateral tongue.

Has been contiuously bleeding for an hour, tachy 130, normal BP, has a bag of blood in hand ~ 1000 ml.

Vomited a few times – altered blood / coffee grounds

On examination there is a fungating lesion that we cannot see past ie. You can see the front of the lesion covered in an oozing clot but it extends past the possible field of view around the back of the tongue.

The jaw is microagnathic / graft with a lot of scar tissue.

The anterior larynx is best described as a block of fixed tissue with woody texture. It is impossible to clinically feel the cricothyroid / thyroid cartilage or membrane reliably

Ix

Bloods – Hb is now 79 (was 110 on recent check). Platelets 150

Normal renal function

Coags are normal

LFTs – raised GGT and ALT – chronic

No imaging / CT available

The problem

This patient is exsanguinating – we need to control the bleeding. IV TXA, topical adrenaline and TXA gauze help control external bleeding, but she still seems to be gagging and swallowing a lot of blood, vomiting intermittently coffee grounds.

We have blood to transfuse ready to go…

To do this properly we need to control the airway / get a tube in place.

How should we do this…?

AFOI – is going to be tricky

RSI – also requires we accept the risk of going to surgical airway…. Which may be tricky

Needs to go to the tertiary hospital on a plane… this is unlikely to occur without a secured airway.

OK doc – the surgeon is scrubbed and ready to get in there… what the plan?

What do you do if AFOI proves to be impossible / failed?

Have a listen to hear how it played out and what the airway experts think!


Casey

First10EM Journal Club: November 2017

Welcome back to the Journal Club with Dr Justin Morgenstern.  It has been 2 months since we last dusted off the papers on Justin’s bedside table… but like a mythical (nerdy) Sisyphus Justin must push another load of evidence out into the ether in order to go back and start the whole process again.

This episode is on steroids.  I mean it is largely about steroids, not actually “on steroids” but there is a sprinkling of other stuff and a bit of philosophical banter about machine learning at the end.

So sit back, grab a beverage and tune in for another hour of evidence and education from our corners of the world. You can read Justin’s written thoughts over at First10EM now

Here are the papers:


Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents. The American journal of emergency medicine. 2006; 24(2):177-82. PMID: 16490647

Bottom line: We really need to get our acts together and get droperidol back in our emergency departments.


Roldan CJ, Chambers KA, Paniagua L, Patel S, Cardenas-Turanzas M, Chathampally Y. Randomized Controlled Double-blind Trial Comparing Haloperidol Combined With Conventional Therapy to Conventional Therapy Alone in Patients With Symptomatic Gastroparesis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2017. PMID: 28646590

Bottom line: Until someone brings droperidol back to Canada, haloperidol will remain a key component of my cyclic vomiting management strategy.


Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ (Clinical research ed.). 2017; 358:j3887. PMID: 28931508 [free full text]

Bottom line: Steroids will decrease pain from pharyngitis, although the exact balance of harms and benefits is probably not known.


Waljee AK, Rogers MA, Lin P. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ (Clinical research ed.). 2017; 357:j1415. PMID: 28404617 [free full text]

Bottom line: We know there are adverse events from steroid prescriptions, but this study really doesn’t give us much information.


Qaseem A, Harris RP, Forciea MA. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Annals of internal medicine. 2017; 166(1):58-68. PMID: 27802508

This is a well done clinical practice guideline (meaning transparently based in evidence) with a few decent take homes about gout for emergency practitioners.


Callaham ML. The Prudent Layperson’s Complicated and Uncertain Road to Urgent Care. Annals of emergency medicine. 2017. PMID: 28935282

Bottom line: Stop blaming patients for using the emergency department. We have system issues and societal education issues that we need to address, but for now I am happy to look after any patient who is scared about their health.


Daum RS, Miller LG, Immergluck L. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. The New England journal of medicine. 2017; 376(26):2545-2555. PMID: 28657870

Bottom line: Some patients will benefit from antibiotics after I+D of their abscess.


Gottlieb M, Russell FM. How Safe Is the Ultrasonographically-Guided Peripheral Internal Jugular Line? Annals of emergency medicine. 2017. PMID: 28969927

Bottom line: The ability to rapidly (and safely) place a peripheral IV into the internal jugular could be lifesaving in the correct patient, but shouldn’t be used routinely.


Cabitza F, Rasoini R, Gensini GF. Unintended Consequences of Machine Learning in Medicine. JAMA. 2017; 318(6):517-518. PMID: 28727867

AND

Ziad Obermeyer, Thomas H. Lee.   Lost in Thought — The Limits of the Human Mind and the Future of Medicine
N Engl J Med 2017; 377:1209-1211  September 28, 2017

Bottom Line:  Machines may help us make better decisions in the future. But we still need to know what the data input looks like and what goes on inside the black box!


OK Here is the podcast, thanks for joining us once again.  Comments are always welcomed.

Casey

Clinical Case 142: Studying Swooning at Sixteen

Welcome back – this is the first case for a long while and it is also the first case presented on the new podcast segment!

The working Title is: Rob’s Probs and Casey’s Cases  (Ed: may change if we come up with something better)

The new podcast series is all about CLINICAL REASONING.  Exploring how we think through a diagnosis or problem.  IN order to do this I have teamed up with Dr Rob Park, a Queensland GP from the “Sunny Coast”, sounds delightful!  Rob has been on the podcast way back in December 2013 when we chatted about the evils and virtues of Vitamin D.  Since then Rob has been busy working as a GP, writing the RACGP written examination (yep, I know, you would think the bloke writing the exams is a total douchebag… turns out the opposite is true!) and becoming a father – so he clearly has a lot of time on his hands…

The aim of this podcast is to share some clinical cases, not so much to Stump the Chumps (see IM Reasoning for that) but more to show how a prudent senior GP might think their way through a clinical problem.  At least that is what I told Rob… now to try and fool that clever fella!

I have presented this case in stages – broken by horizontal lines – the idea is that you stop at each line and consider what is important, the differentials what you need to think about in the next phase.  Clearly there will be some questions you need to delve into later as more information becomes available.  But to pass the exams it is a good idea to start forcing yourself to pause and think “what next” or “where am I now” as the case unfolds.

Here is the case:

You are working in your suburban GP clinic.  Your next patient is Marli.  Marli is a 16 year old, final year highschooler.  You have not seen her since she was a little kid.  She presents with her mother whom you know quite well.  Marli is currently on study break leading into her final TER exams and her family have high expectations…

She has no ongoing medical problems and is quite fit, doing performance gymnastics up until final year school.  She has no other background issues.


Today she presents with a bruise on her forehead.  She tells you that she collapsed in the bathroom this morning and bumped her head on the vanity… she cannot recall anything for a few minutes.  This happened after she sat on the toilet to urinate then stood up.

Mum was in the next room and heard her fall and saw her on the floor.  Mum observed her laying on the floor and had what seemed like 2 or 3 brief jerky movements of all four limbs. After that she rapidly regained consciousness and sat up.  She was a bit dazed for 20 seconds.  Mum says it was about 30 seconds in total between her initial fall and being alert again.  Mum didn’t notice anything else… no tongue biting or incontinence.  The head bump is small, no laceration over the left eyebrow.

Marli says she has no aura or warning, she just suddenly felt weak in the legs, her vision “tunnelled” and she went limp.

She did not notice any palpitations or nausea.  There was no antecedent painful or particularly emotional events.

Over the last few weeks she has had less sleep as she has been studying late and drinking a lot of coffee to “stay awake”.  She has started doing regular exercise (running) to help with exam stress.  She has had a few episodes where she has felt light-headed on exercising but not actually fainted.


She has had some heavy menstrual periods in the last 18 months and was advised to take iron supplements by the school nurse.  She takes these sporadically.  She has not had any infective sounding symptoms such as fever, cough, coryza, dysuria… she has no abdominal pain or other symptoms.

Marli is happy to talk about her private life with Mum in the room, she says she has not ever been sexually active.  She does agree to undergo a urinary HCG “to be sure”.

Family history: Marli’s paternal uncle died suddenly, aged 30, when swimming on holiday in Greece… unclear as to exact cause.

Meds – intermittent oral iron supps, some vitamins


ON EXAMINATION

Marli is a tall, thin healthy looking young woman.  Her Obs: pulse 80 regular, BP 105/65 sitting (110/70 on standing), SpO2 99%

No clinical anaemia or pallor.  Skin is tanned.

Heart sounds are dual, normal, no bruits /clicks or thrills.  She has strong peripheral pulses.

Chest is clear

Abdomen soft.  No tenderness, or masses

Urinalysis is NAD with a negative bHCG

random BSL is 5.O mmol/L


Marli’s ECG is as follows:

courtesy LITFL ECG Library & Heart Pearls

OK, so let us stop there.  Look at the ECG and describe or diagnose it.

What next? How will you proceed from here?

If you know the diagnosis – then well done.  However if you want to hear this case dissected in audio format – have a listen to the podcast episode below.