To the Editor:- Airway management of a patient in halo traction may be difficult. These difficulties may be compounded by additional challenges, including the emergency need for airway management, e.g., cardiac arrest;multiple previous laryngoscopies; or patient anatomic features that indicate difficult tracheal intubation.
An 89-yr-old man with a medical history of hypertension and disseminated prostate cancer was admitted to the hospital for treatment of a posterior C2 fracture sustained in a fall. A halo device was placed the previous day without complication, and the patient was in a telemetry unit, although in an unmonitored bed. At approximately 1:00 AM, the patient had generalized seizures followed by unresponsiveness. An electrocardiogram showed asystole. Chest compressions and bag-mask ventilation were instituted by the internal medicine team leading the resuscitation, and 5 mg epinephrine and 1 mg atropine were administered. Five attempts at direct laryngoscopy, using Macintosh-3 and Miller-2 blades, were unsuccessful. Ventilation by mask became more difficult in part because of gastric air distension, although the patient had an idioventricular rhythm. The Anesthesiology Department was subsequently consulted for airway management. Laryngoscopy and anesthesiology residents using Macintosh-4 and Miller-3 blades revealed only the tip of the epiglottis. At this point, an anesthesiology attending physician, recently apprised of the situation, arrived with a Bullard laryngoscope with a blade extender and multi-functional stylet. Bullard laryngoscope placement in the oropharynx was difficult because of lingual swelling. A partial view of the vocal cords beneath a swollen epiglottis was obtained. An 11-French Cook airway exchange catheter (Cook Critical Care, Bloomington, IN) was advanced through the vocal cords via the hollow multifunctional stylet, and a 7.0-mm endotracheal tube was advanced over the multifunctional stylet, airway exchange catheter and passed through vocal cords on the first attempt. Bilateral breath sounds were noted, and the endotracheal tube was secured. A brief episode of ventricular tachycardia after intubation was treated successfully with synchronized cardioversion, and the patient was transferred to the intensive care unit with an oxygen saturation of 100%(FIO2= 1.0) stable hemodynamics, and a normal sinus rhythm, and receiving an epinephrine infusion of 0.05 [micro sign]g [middle dot] kg-1[middle dot] min-1. At subsequent examination, the patient was micrognathic with a submental distance of two fingersbreadth. Unfortunately, the patient died in the intensive care unit approximately 4 hours after the initial episode of cardiac arrest.
Although a fiberoptic bronchoscope has been recommended for elective tracheal intubation with a halo device, moving one from the operating room and using it in this episode of cardiac arrest would have been extremely difficult. We recently found that the Bullard laryngoscope allowed more rapid tracheal intubation than the fiberoptic bronchoscope did in an unselected population with unstable necks for elective surgeries. Notably, intubation was performed with any preexisting neck immobilization devices left in situ. Unfortunately, successful use of the Bullard laryngoscope necessitates almost as much experience as the fiberoptic bronchoscope, relatively few training programs educate residents about Bullard laryngoscopy, and only 35% of practice settings recently surveyed have one rapidly available, whereas approximately 93% have a fiberoptic bronchoscope rapidly available. Cricothyroidotomy would have been a reasonable option and would have been the procedure of choice had the Bullard procedure failed. However, even with this procedure, a significant failure rate may exist. In one study, a cricothyroidotomy procedure could not be successfully completed by an Advanced Trauma Life Support verified physician in 10.4% of patients. If cricothyroidotomy had failed, bleeding into the airway could make any subsequent fiberoptic technique, e.g., Bullard laryngoscopy, impossible. However, it is extremely unlikely that attempted Bullard laryngoscopy would make a subsequent cricothyroidotomy more difficult.
In summary, the Bullard laryngoscope worked well here, because it was readily available and easily portable and we were familiar with its use. It allowed tracheal intubation with direct visual confirmation in difficult circumstances
Aaron I. Cohn, M.D., M.A.
Mark Lau, M.D.
Jason Leonard, M.D.
Resident; Department of Anesthesiology; University of Oklahoma Health Sciences Center; Oklahoma City, Oklahoma
(Accepted for publication April 22, 1998.)