traumatic intubation

[Lydia12]

Recently, we had a patient who following surgery, was extubated and went to the PACU. While there, the patient was reported as having stridor, resulting in reintubation. It took three difficult attempts to reintubate this patient, during which three bottom teeth in the front were broken. We "heard" that someone who "never fails an intubation" was called to assist, and it still took three difficult attempts. On the unit, blood was discovered in the patients ear and later it was discovered that there was a ruptured tympanic membrane. The three teeth were extracted also on the unit. The eardrum is being blamed on the difficult intubation. The patient has a fairly recent history of a lengthy hospitalization with 25 days on the vent followed by three months of being trached. The patient also has a lengthy medical and surgical history including "difficulty with intubations", extubations, weaning, a past CABG, vascular issues, cardiac arrest, ARDS, DM, and HTN.

Now the patient is of course mechanically ventilated and discussion is ongoing as to whether the patient should be trached now, or later. I am interested in other opinions as to what else (if else) could of been done with the patients best interest in mind during the difficult intubation, that might of spared the broken teeth and the ruptured eardrum and the now very traumatized trachea! I also had to post this here because since I am not a SRNA yet, it wont let me post in a more appropriate place.

[gaspasserval]

Could you or someone on here explain to me about the difficult airway caused by the ruptured tympanic membrane? That went over my head. :2in1:

It's hard to say what could have been done differently because none of us were there to examine his airway. I wonder if a light wand or FOB could have been used. When I was working in the trauma ICU before school, we did trachs under local at the bedside. I wonder if this could have been an option but it is hard to say. Maybe one of the more experienced anesthetists on here could comment on that.

[Lydia12]

Could you or someone on here explain to me about the difficult airway caused by the ruptured tympanic membrane? That went over my head. :2in1:

It's hard to say what could have been done differently because none of us were there to examine his airway. I wonder if a light wand or FOB could have been used. When I was working in the trauma ICU before school, we did trachs under local at the bedside. I wonder if this could have been an option but it is hard to say. Maybe one of the more experienced anesthetists on here could comment on that.

we were told that the ruptured tymp. membrane occured due to the amount of blood/fluid caused by the airway being traumatized while trying to secure it. I visualized this in the same way that an eardrum can rupture when infection is present and building, causing a burst eventually. Only my idea though; thats why I am asking for anyone who might really know.

[gaspasserval]

I misunderstood what you said when your wrote "the eardrum is being blamed on the difficult intubation." I think you meant "the eardrum was caused by the difficult intubation?" Still haven't heard of that but I guess anything is possible.

[athomas91]

1. was the patient a difficult intubation the first time - if so - should they have waited longer to extubate??
2. hind-sight is 20/20 - and because we don't know the exact patient info and what was happening it is hard to speculate what to do differently - if the patient was stridorous - the correct move was to reintubate - perhaps they had no issue intubating for surgery and didn't anticipate problems reintubating - when they encountered problems - the "correct" step it to wake the patient and FO intubate but this may have not been a "correct" step with this patient due to airway compromise already in place - broken teeth is an unfortunate complication of intubation but it is a risk - and it would be completely unprofessional of me to tell you that it shouldn't have happened - because it does happen and you have the choice between a broken tooth or a dead patient - i will take the tooth....
as for the ruptured tympanic membrane - i cannot think of any reason an intubation traumatic or otherwise would rupture it.

[jwk]

My guess on the ruptured TM would be barotrauma from some over-agressive ambu-bagging.

[Catcolalex]

The eardrum trauma is a common side effect of a little-known difficult airway technique know as trans-tympanic trachial intubation. :eek5:

[RAYMAN]

The eardrum trauma is a common side effect of a little-known difficult airway technique know as trans-tympanic trachial intubation. :eek

What size tube do you use for that? I assume you used an uncuffed one. :stups:

[Catcolalex]

Uncuffed, with generous amounts of lubrication.

[athomas91]

ROFLMAO

i think i will forgo learning that technique... :)

[gaspasserval]

So you go trans-tympanic and then curve around into the larynx?

As Dr. Evil would say " Riiiiiiiiiight!"

Are there special McGills for that? :pound: :pound: