Emergent Intubation in a 63-Year-Old Female with Altered Consciousness and Complicated Airway

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-9-2025

Abstract

Emergent airway management is a critical life-saving skill, complicated further in patients with a history of difficult intubations or anatomical challenges. Patients that have limited neck mobility from conditions like rheumatoid arthritis or prior cervical surgeries present unique complications and often require advanced techniques. Nasal intubation offers an additional route when first-line approaches fail, but its role in emergent situations is not well-defined.1 This case illustrates the challenges of securing a difficult airway after repeated attempts and highlights the necessity of multidisciplinary approaches to reduce mortality.

A 63-year-old female with a history of difficult intubations, rheumatoid arthritis and occipital-cervical fusion presented to the ED with altered mental status following a fall. She experienced a seizure witnessed by EMS during transport. She was transferred to the ICU after ED assessment indicated she was encephalopathic, tachypneic and required emergent intubation. Her airway was complicated by limited neck mobility, prior odontoid fracture and a history of tracheostomy.2 Past intubations had required multiple attempts with advanced airway techniques, including bougie-assisted intubation and LMA placement after failed intubation attempts.3

Multiple intubation attempts were made with Mcgrath, bronchoscopy and Glidescope in ICU. First Mcgrath only visualized soft tissue, was removed and bag masked ventilation resumed. Bronchoscope was used to determine if tube could be placed over it. Further Glidoscope, combined video scope and bronchoscope attempts were unsuccessful. Despite multiple modalities, the patient's history and anatomy limited visualization of airway structures. EM and general surgery were consulted about tracheostomy, but concerns arose due to past trach, distorted anatomy, and limited neck mobility. Reversal medications were given. After more attempts, team transitioned to nasal approach while waiting for general surgery and possible surgical airway.4 Initially, the ET was passed over scope into the esophagus, causing SpO2 drop. It was repositioned into trachea with bronchoscope guidance. Ultimately airway was secured, allowing for continued care. Post-intubation, the patient developed subcutaneous emphysema, confirmed by CT imaging.

This case highlights the complexity of managing difficult airways in emergent situations. A multidisciplinary approach and advanced techniques like nasal intubation are crucial in overcoming anatomical challenges. Recognizing potential complications, like subcutaneous emphysema, and considering alternative strategies are essential to improve outcomes. Nasal intubation, though not routine, may be an option given its ability to directly visualize the vocal cords. This case underscores the importance of preparedness and adaptability in evidence-based medicine.

Comments

2025 Research Day Corewell Health West, Grand Rapids, MI, May 9, 2025. Abstract 1737

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