ICU Fellowship Vivas – Can’t Intubate, Can’t Ventilate & C-Spine Injury
Dr Swapnil Pawar
Written by – Dr Madhuri Anupindi
This is a life-threatening situation as this patient has signs of acute airway obstruction with a high risk of complete loss of his airway. My priorities are to urgently secure this gentleman’s airway, ensure adequate oxygenation and haemodynamic optimisation, and simultaneous assessment and management of the cause of his obstruction. My main concern would be an expanding haematoma causing external airway compression but other causes could be anaphylaxis, residual neuromuscular blockade, post-extubation stridor, or less likely recurrent laryngeal nerve injury.
Outline three techniques that could be considered to secure this gentleman’s airway and their advantages and disadvantages?
There are several techniques available to secure this gentleman’s airway, choice of which will depend on equipment, staff availability, experience and personal preference.
Rapid sequence induction with video laryngoscope and high dose of paralysis:
Awake fibreoptic intubation
This patient undergoes an RSI and is unable to be intubated by the anaesthetist despite optimisation strategies. He is unable to be effectively oxygenated using supraglottic devices or a bag valve mask. You decide to perform a cricothyroidotomy. How is this performed?
This is a life-threatening situation and a can’t intubate can’t oxygenate emergency situation should be declared. 100% Oxygen should be still administered via the upper airway and the patient should be appropriately anaesthetised and paralysed. They should be positioned with the neck extended and all monitoring in situ and necessary equipment available including emergency drugs and the arrest trolley.
Equipment required for the cricothyroidotomy is a scalpel, bougie, cuffed size 6 ETT, lubricant, 10ml syringe, tube ties, end-tidal co2. The technique used depends on whether the cricothyroid membrane is palpable or not (it may not be in this gentleman due to his obesity).
If cricothyroid membrane palpable:
Impalpable cricothyroid membrane
Post cricothyroidotomy care:
This gentleman has had a significant trauma with a likely cervical spinal cord injury. He requires initial resuscitation and management as per ATLS guidelines including a primary survey, secondary survey, definitive management and supportive management.
Airway and C spine:
Breathing and ventilation
Definitive management of injuries
How would you clinically assess this patient’s level of injury?
The patient’s level of spinal injury is assessed using the American Spinal Injury Association (ASIA) Impairment Scale. This involves a standardised examination consisting of a myotomal based motor exam, dermatomal based sensory exam and an anorectal exam. The findings of these exams then determine the injury grade and level. This assessment is often done later during the admission as it requires resolution of any neurogenic shock, the absence of distracting injuries, and for the patient to be alert, co-operative and able to communicate, respond and follow commands.
What are the characteristic features of a cord transection versus central cord syndrome?
Central cord syndrome
What are the physiological consequences of a cervical spinal cord injury?
Initially tone decreased à eventually this will increase and UMN signs develop
Anal tone lax in complete lesion
Weakness and sensory loss will depend on level of injury
Reflexes initially absent but will increase with time
Upgoing plantar reflex
Decreased maximum tidal volume
Rapid respiratory fatigue
Increased vital capacity in supine position
Poor cough and difficulty with clearance secretions
Decreased peripheral vascular resistance
Increased alpha-adrenoceptor responsiveness
Loss of postural homeostatic reflexes
Fixed cardiac output
DVT and PE
Decreased gastric transit, acute gastric dilatation
Acute gastric dilatation due to body cast syndrome
Hypercalcaemia, osteoporosis and renal calculi
Disordered thermoregulation à hypothermia
May have priapism immediately after injury
Briefly outline the role of early decompression in spinal cord injury.
Early surgical decompression in spinal cord injury is usually defined as within 24 hours of injury and may reduce the length of ICU stay and post-injury complications. The rationale behind it is that decompression may relieve pressure within the cord parenchyma which may partially restore microvascular blood flow, reduce ischaemia, and remove mechanical compression of the neuroglial cell membranes. Spinal surgery can also facilitate restabilisation of the spine.
Early stabilisation also helps to facilitate easier nursing care and positioning.
The optimal timing of decompression in spinal cord injury is unknown but evidence favours earlier decompression.