COVID-19: Difficult Airway

This case was written by Drs. Stephanie Pilieci and David Ha. Dr. Pilieci received her MD from the University of Alberta and is currently a PGY-2 resident in the FRCPC-EM program. Dr. Ha is a staff emergency physician at the University of Alberta and the Assistant Program Director of the FRCPC-EM program.

Why IT matters

When the covid-19 pandemic started, guidelines for safe airway practice included: the use of
video laryngoscopy, the avoidance of active bagging and the minimization of staff members in
intubation rooms. However, these guidelines will often need to be overruled if there is a failed
intubation attempt. This case is designed for groups to practice pandemic airway management
when the Plan A video intubation method fails. Specific issues to address include: the need for
bagging a patient in extremis, coordinating having the backup physician enter the room to help
and the need for bringing in extra supraglottic and surgical airway equipment if the situation
warrants.

Clinical Vignette

Mr. Johnson, a 60-year old man was found at the bottom of 3 steps at home by his wife. He is obtunded with obvious bruising to head. EMS has placed him in a C-spine collar and provided supplemental oxygen. He was swabbed for COVID yesterday due to a new cough and fever and the results are still pending.

Case Summary

A 60-year-old male with obvious head injury and respiratory failure arrives to the ED in C-spine precautions during the COVID-19 pandemic. Because of the c-spine immobilization and COVID precautions, the team tries hyperangulated video laryngoscopy in their initial airway attempt.

However, this attempt will not be successful and the patient will desaturate, necessitating bag-valve masking. At this point, ventilation will become difficult, even with optimized two-person BVM technique or placement of a supraglottic airway. The team leader will be required to exhaust the entire difficult airway algorithm, calling for addition supplies and personnel and finally securing an airway with a surgical approach.

Download the Case here: COVID Difficult Airway

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