Monday, December 2, 2013


A morbidly obese middle aged man with unknown past medical and surgical history has a motorcycle crash. All his injuries are above the neck. He has multiple facial fractures, orbital fractures, mandibular fractures, tongue lacerations, CSF rhinorrhea, and scalp hematomas. On arrival, he is obtunded. Bag-mask-ventilation is impossible with the jaw fractures. An attempt is made to intubate him but nothing can be visualized. An attempt to place a laryngeal mask (LMA) also fails. The patient begins to desaturate.

You come to the rescue. After identifying the appropriate landmark and scrubbing with povidone-iodine, you place a needle with a syringe half-filled with saline into the airway at 30-45 degrees directed caudally. When you see air bubbles in the syringe, you advance a catheter, remove the needle, and confirm placement again. Then you connect the catheter to a bag-valve-mask, confirm CO2, and call a surgeon for a definitive procedure.

An X-ray is shown below.

Challenge: What procedure did you perform and what complication do you see above?

Image shown under Fair Use.


tree said...

Look at all that subQ emphysema! What did you do??? In reality (hopefully), the trauma team would've been there at the bedside already evaluating the patient. They would've been able to do a cric instead of all this putzing around with a needle nonsense ;-)

Craig Chen said...

yes, you're right :)

This is needle cricothyroidotomy with percutaneous transtracheal ventilation. The X-ray shows subcutaneous emphysema.

Sources: UpToDate; LearningRadiology.