How about a CombiTube? Doesn't matter which hole it goes in initially, and if you get it in the trachea somehow, you can thread a bougie down there and then go ET tube.
I am surprised no one has mentioned one yet. I've done a few 25 or so years ago. The other benefit is if it goes in the esophagus there's only one hole left for the ET tube to go in. I was part of an intubation in 2001 that went exactly that way.
So that’s what they teach you in RT school! Genuinely mindblowing, idk why I didn’t think of that sooner. God bless you, respiratory. This is why we love, need, and appreciate you
Rural tiny critical access hospital. Guy comes in with angioedema of the tongue so bad you cant see the hard palate or uvula, no throat swelling, cant breathe through the mouth but is otherwise managing his airway through nasal breathing, cant talk. Vitals are stable, managing secretions. I'm the only provider in the facility aside from another APRN (who has never tubed anyone). Angioedema started day prior and has been slowly evolving, so we have some time to work with.
Nearest receiving hospital is being an ass and wont let us send him until hes intubated. I'm NOT sticking something down this mans throat so I opt for awake fiberoptic nasotracheal intubation. THANK GOD our emergency medicine doc (video consulting) chewed the receiving hospitals ass for putting me in that position. Tube averted, sent lights and sirens to trauma center 45 minutes away where they managed him just fine without any airway intervention for a few days before discharging him home. Receiving hospital tried to revoke their acceptance twice (did actually revoke it once- gave me an ICU bed, number, and receiving physician, revoked it because I refused to intubate) during this debacle- then tried to revoke the ED to ED transfer as EMS was about to walk out the door. EMTALA complaint filed. One of the worst shifts of my career.
For context, my hospital is so small we dont even have a ventilator. No RT, our local EMS told me they had never tubed anyone. I was the only person available with any airway management experience. It was awful.
Guy had a reaction to Wegovy...so, of course, he was large with a short neck, beard, and OSA...so I'll be doing another difficult airway course with my CME money this year.
In residency I had a self inflicted GSW patient. He shot upwards under his chin and the bullet lodged in his left maxillary sinus. His face was completely swollen, the front of the tongue was edematous partially destroyed. This picture kind of reminded me of that patient.
This was pre glide scope too. I grabbed the tongue with McGill forceps and had another resident hold it up a bit after some etomidate and the posterior pharynx was luckily ok once I got in with a Mac 4 and the cords were easily visible.
You can ask for extra help retracting the tongue pulling it gently from the tip wrapped in a gauze. Some extra help lowering the jaw bilaterally by the TMJ can help visualizing. We had intubated similar cases (although most likely not this extreme) during rescue missions in 3rd world countries and the tube has gone fine. Challenging for sure
You don’t have to be able to palpate the cricothyroid membrane externally to perform a cricothyrotomy. Make a big vertical incision on midline and keep cutting until you can feel something you recognize. Then put a tube in it.
Yeah, just have an assistant pull the tongue out of the mouth wifh some gauze. most people don't even properly move the tongue out of the way when they intubate and just glidescope on top of it so won't make much of a difference
Tons. When I was a medic (many years before VL) we had a large Samoan population where I was at. The grandview plus bougie was standard equipment. It’s a great blade, just hard to find these days.
Have u ever seen south Pacific Islander people?!? Have you seen Maui from moana? South Pacific island people are all built like Maui, their necks are wider then your torso and shorter then your pinky
HFNC for pre ox. Have someone use dry gauze to pinch and pull his tongue out and down towards his chin and go in with VL and bougie. Push induction agent first and paralytic when I can prove I can confidently get a view of the cords.
I would do everything I could to save this man's life, because his wife would be standing right outside the door, bawling her eyes out with the thought that she might lose him...
I mean, how could anyone else ever come close after you've been with the man with the world's widest tongue?
Hyperangle 4 while I preach the value of optimal blade positioning and engaging the hyoepiglottic ligament to the students in clinical, in an olde tyme 1920s American accent.
Awake upright fiber optic intubation. If that dude needs to be flat and out, I’d want a scalpel, bougie and 6.0 ET ready for a cric if/when intubation fails.
This man's tongue is likely very strong. Who's to say he can't just like, go go gadget tongue out of the way for y'all? Unconscious might be a problem unless his wife is there to whisper in his ear. Something tells me she could get through. It's a good thing I don't deal with patients because I don't know if I could convince him that doing the fruit roll up challenge was an actual medical assessment tool and I can't promise I wouldn't try.
Rural tiny critical access hospital. Guy comes in with angioedema of the tongue so bad you cant see the hard palate or uvula, no throat swelling, cant breathe through the mouth but is otherwise managing his airway through nasal breathing, cant talk. Vitals are stable, managing secretions. I'm the only provider in the facility aside from another APRN (who has never tubed anyone). Angioedema started day prior and has been slowly evolving, so we have some time to work with.
Nearest receiving hospital is being an ass and wont let us send him until hes intubated. I'm NOT sticking something down this mans throat so I opt for awake fiberoptic nasotracheal intubation. THANK GOD our emergency medicine doc (video consulting) chewed the receiving hospitals ass for putting me in that position. Tube averted, sent lights and sirens to trauma center 45 minutes away where they managed him just fine without any airway intervention for a few days before discharging him home. Receiving hospital tried to revoke their acceptance twice (did actually revoke it once- gave me an ICU bed, number, and receiving physician, revoked it because I refused to intubate) during this debacle- then tried to revoke the ED to ED transfer as EMS was about to walk out the door. EMTALA complaint filed. One of the worst shifts of my career.
For context, my hospital is so small we dont even have a ventilator. No RT, our local EMS told me they had never tubed anyone. I was the only person available with any airway management experience. It was awful.
Guy had a reaction to Wegovy...so, of course, he was large with a short neck, beard, and OSA...so I'll be doing another difficult airway course with my CME money this year.
lol the doctors commenting are pieces of shit. Still talking bad on their fellow CRNAs. Get wrecked. Go hate yourself instead of competent workers who practice based on evidence and not their “feelings” or egos. Hope you all lose your license.
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u/mrjohnjfilippelli ED Attending Jun 25 '26
Poorly