This is the fourth case in a series looking at critical care medicine. Patients under the care of the critical care team may develop delayed complications of their illness or injuries. These cases can help individuals and teams prepare to identify and manage these patients who become newly, and sometimes unexpectedly, unstable.
This case comes from Dr. Dominique Piquette, academic Intensivist at Sunnybrook Hospital in Toronto, Ontario with updates from Dr. Sameer Sharif (Hamilton Health Sciences, Hamilton, Ontario) and Dr. Ailish Valeriano (Emergency Medicine Resident, McMaster University, Hamilton, Ontario)
Why it Matters
Post-extubation respiratory failure occurs in up to 10% of extubations and can be caused by inability to ventilate spontaneously or by inability to tolerate removal of ETT. Causes of extubation failure include upper airway obstruction and secretions.
Re-intubation is a fraught procedure, especially for trainees. They must strike the right balance between assertiveness and collaboration with the bedside team. Developing an airway plan requires consideration of anatomic and physiologic changes that have taken place since the initial intubation. Medical options are limited. The ability to communicate plan and organize resources in a timely manner is essential to a successful re-intubation.
Clinical Vignette
A 59-year old man in your ICU was just extubated 30 minutes ago. He is four days post blunt polytrauma and has ongoing agitation but no other requirement for intubation. Since extubation, he has required several sedatives and has now developed stridor at rest. The nurse and respiratory therapist at the bedside are advocating for calling the staff intensivist for immediate re-intubation.
Case Summary
A 59-year old man was the intoxicated driver in a single car MVC. He was intubated and admitted to ICU with brain and bony injuries. The patient has been agitated and delirious throughout his stay. The decision is made to extubate. However, the patient is quite agitated and requires sedation by nursing staff. Following extubation, he becomes stridorous and develops progressive respiratory failure. The team will need to manage the patient’s airway, eventually requiring re-intubation. Subsequently, the patient’s spouse will need to be informed of the patient’s status as well as the indications for re-intubation.
EM Sim Cases 