Case 25: A Tracheotomy Is Urgently Needed and You Have Never Done One
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You are called stat to the Cath lab for a patient who has developed sudden difficulty in breathing. You find a 73-year-old woman with neck and face severely swollen. She is unresponsive with shallow, rapid, and labored breathing. She is receiving nasal oxygen at 4 l/min and the oxygen saturation is 86%. She has a diagnosis of a superior mediastinal syndrome. In an attempt to investigate this, the radiology staff has sedated the patient with IV fentanyl 100 microgram and IV 4 mg of midazolam. With the patient adequately sedated, a Shiley catheter has been placed in the right subclavian vein. They inform you that the subclavian artery has also been hit several times and there is now a large hematoma compressing her trachea. You listen to the chest but can hear little air entry. You assist ventilation with 100% oxygen via an Ambu bag, but with no improvement. You attempt to intubate the trachea with a Mac 3 blade but see nothing. You feel that succinylcholine will not be helpful as the patient is now relaxed and completely unresponsive. A two-person mask ventilation with a large oral airway is unsuccessful. The LMA that you have called for has not arrived. The neck is so swollen that you dismiss the use of a cricothyrotomy. A tracheotomy set is produced, and an ENT specialist is called for, but you are informed that he can only be there in 10 min. The oxygen saturation is now 76%, and there is a dramatic decrease in her pulse rate and blood pressure. Everyone is looking at you as the senior anesthesiologist. You know that you have never done a tracheotomy before by yourself and certainly never under these circumstances. However, since you have seen many tracheostomies, you feel this is the only option for this woman. You grab the scalpel and feel a great sense of insecurity and dread, but you have committed yourself as you make the incision.
KeywordsTracheotomy Respiratory arrest Superior mediastinal syndrome Ambu bag Scalpel
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