Oral board challenge

[Laurel123]

Hey guys,

25 year old G1 at term comes into labor floor in labor. She is 300 pounds, short, with a short fat neck, Mal 4 mouth and a big fat face. No previous surgeries. Check the baby, and baby is down, down, down - OB's pages for a emergent C/S and that is where we meet her for the first time. She looks like the type of patient I would intubate awake if she walked in for elective surgery, but now the OB's are saying we need to get the baby out NOW.

Now do you proceed?

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[militarymd]

Options

1) Start under local while you get the airway

2) spinal catheter

3) prop, sux, tube, pray


My personal practice is 1)....have done it a couple of times.

 

[InGasWeTrust]

Im still a resident, but we very frequently mentally masterbate over this exact topic as our patient population averages 250lbs and often have comorbid conditions.

From our discussion there are 2 thoughts.

1. Given that there are a host of airway devices that can temporize and or "fix" a bad airway, then you induce. The caveats are you have an extra set of hands, you have a LMA, combitube, jet ventilator and you are calling trauma surgery that you need them STAT.


2. Second thought, basically if you are forced into that situation, and you feel that if you induce this lady she most likely will either be a veggie or die then you DONT! Reason is you dont know how long the baby has been hypoxic, and even if you get the baby out it may still be a "BAD" baby. Also you never kill the mother to save the baby. Obviously if you go with this, be prepared to be sued and have bad blood with the OB dept. I personally know of an attending who made this call, came thru unscathed and sleeps well knowing he did not kill 2 patients.


I would assume the board answer is along thought process #1.

 

[UTSouthwestern]

Vitamin K(etamine)

 

[Bougie]

Ketamine?...explain please.

 

[Planktonmd]

If this is for the Oral board then the safest answer would be awake intubation.[/COLOR]
In real life RSI , ETT and have a couple of alternative airway devices available.

 

[johankriek]

Options

1) Start under local while you get the airway

2) spinal catheter

3) prop, sux, tube, pray


My personal practice is 1)....have done it a couple of times.

the answer is.. awake fiberoptic (on the oral boards)
if you try to do anything slick like the above.. YOU WILL COME BACK NEXT YEAR>....
attack the airway awake...

i cant believe military passed the orals with that answer..
and if you put this lady to sleep knowing you are not going to be able to intubate. its frankly malpractice.. pray on your own life...

 

[militarymd]

Options

1) Start under local while you get the airway

2) spinal catheter

3) prop, sux, tube, pray


My personal practice is 1)....have done it a couple of times.

the answer is.. awake fiberoptic (on the oral boards)
if you try to do anything slick like the above.. YOU WILL COME BACK NEXT YEAR>....
attack the airway awake...

i cant believe military passed the orals with that answer..
and if you put this lady to sleep knowing you are not going to be able to intubate. its frankly malpractice.. pray on your own life...

I always tell people to read.....obviously you are one of those who need to listen to my advice...

Options...mean all the ways you CAN possibly do it...

then I noted which OPTION I would choose....but because you're one of those who don't read...and just ASSume ....you ASSumed that I would put the patient to sleep....

Foolish....as a physician you should learn to read before you open your mouth...or in this case...start typing....which is even worse...because you had time to think about what you were going to type...and yet you didn't.

 

[Noyac]

I agree with Mil. I assumed he was securing an airway awake while the OB's got started under local.

But of course Ketamine will work fine, but not for the boards.

An LMA will also work if necessary. I have seen this b/4.

Bottom line is do whatever you feel gives the mom the best chance to survive. Awake intubation, RSI, spinal. I don't care. If it works it was the right choice.

 

[UTSouthwestern]

You'll be lucky if that is the board question you get.

Ketamine and local would work for the boards, but they would then just add a modifier to your case (patient vomits during manipulation of the uterus, massive blood loss - patient now in CP arrest, etc.) and see how you would react and what your next step would be or anything to get you back to a difficult airway situation requiring intubation. Just be sure to say you would have the difficult airway cart in the room and appropriate equipment ready to go, including the trusty ol cric kit.

 

[dr. mccoy]

For the oral boards, always do what is the safest (for the mother). Securing the airway in the most timely, but safest manner is the answer for the examiner. The awake intubation be it fiberoptic, or any of your other favorites is the answer. You preface your answer by recognizing the difficulty of the situation, will call for immediate help, but also saying that you will not be burning bridges for mom by doing something that will endanger her life. The is one of the classic board questions.