Welcome to a new feature of PAAD – Medicolegal Monday, where I will occasionally present a real case from my archives, and discuss the medical and legal aspects of the case. It’s a little longer than the traditional PAAD, but I think you will find it interesting.
Great points Michael...I will have to look into the eFONA literature in children. Thanks for the references. I doubt there would be any medicolegal risk in a desperate situation. Doesn't mean family can't sue. In a future ML Monday, we'll explore the reasons families sue. It's usually not the medical care!
I relied on fiberscope and retrograde wire technique to escape CICV situations most of my 30 years of practice... in adults. In recent years, I have converted my approach: "scalpel-bougie-tube", or better to remember, "stab-twist-bougie-tube", is my first choice for impossible upper airway, hands down.
While an ENT was struggling with repeated upper airway attempts a few months ago, I was simultaneously preparing for eFONA (emergency front of neck airway), but he succeeded just before "stab". I was glad. Interestingly, he was a bit uncomfortable with my transitioning preparations (simultaneous efforts to both prevent and prepare for eFONA), despite the rapidly deteriorating situation.
Here is an important article that helps to explain the all too common delay in establishing an airway (in my recent case, and in this tragic Medicolegal Monday case), and suggests ways to prevent potentially the fatal consequences. https://pubmed.ncbi.nlm.nih.gov/32475685/
Finally, a main point: I think I would likely use this eFONA technique on larger, non-toddler children. (BTW, my first choice is to endeavor never to need to use this.) While needle cricothyroidotomy is easy to perform, connecting a tracheal cannula to a ready and effective source of pressurized O2 is problematic for the unprepared, possibly also in our academic centers, too. Scalpel-Bougie-Tube is the 1st line eFONA recommendation of D.A.S., but this appears to apply to adults. Where does the pediatric anesthesiology community stands regarding eFONA, specifically in small children, as in this case. If all you had readily at hand was a scalpel, ped ETT, and ped bougie, would you? Would you be faulted medicolegally for attempting this procedure in the case presented?
A transtracheal 14g catheter is often described but many hospitals aren’t equipped with jet ventilation options. Any other ventilation strategies through an iv catheter? A small ett tip at the top of the catheter with an ambu bag might work, but not sure this has sufficient driving pressure.
Great points Michael...I will have to look into the eFONA literature in children. Thanks for the references. I doubt there would be any medicolegal risk in a desperate situation. Doesn't mean family can't sue. In a future ML Monday, we'll explore the reasons families sue. It's usually not the medical care!
Thanks, Ron!
I relied on fiberscope and retrograde wire technique to escape CICV situations most of my 30 years of practice... in adults. In recent years, I have converted my approach: "scalpel-bougie-tube", or better to remember, "stab-twist-bougie-tube", is my first choice for impossible upper airway, hands down.
https://bjaed.org/article/S2058-5349(19)30066-6/fulltext
https://das.uk.com/content/fona_training
While an ENT was struggling with repeated upper airway attempts a few months ago, I was simultaneously preparing for eFONA (emergency front of neck airway), but he succeeded just before "stab". I was glad. Interestingly, he was a bit uncomfortable with my transitioning preparations (simultaneous efforts to both prevent and prepare for eFONA), despite the rapidly deteriorating situation.
Here is an important article that helps to explain the all too common delay in establishing an airway (in my recent case, and in this tragic Medicolegal Monday case), and suggests ways to prevent potentially the fatal consequences. https://pubmed.ncbi.nlm.nih.gov/32475685/
Finally, a main point: I think I would likely use this eFONA technique on larger, non-toddler children. (BTW, my first choice is to endeavor never to need to use this.) While needle cricothyroidotomy is easy to perform, connecting a tracheal cannula to a ready and effective source of pressurized O2 is problematic for the unprepared, possibly also in our academic centers, too. Scalpel-Bougie-Tube is the 1st line eFONA recommendation of D.A.S., but this appears to apply to adults. Where does the pediatric anesthesiology community stands regarding eFONA, specifically in small children, as in this case. If all you had readily at hand was a scalpel, ped ETT, and ped bougie, would you? Would you be faulted medicolegally for attempting this procedure in the case presented?
A transtracheal 14g catheter is often described but many hospitals aren’t equipped with jet ventilation options. Any other ventilation strategies through an iv catheter? A small ett tip at the top of the catheter with an ambu bag might work, but not sure this has sufficient driving pressure.