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In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn't adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in.
Unfortunately, when you bag the patient, you realize that you are in the esophagus.
Trick of the Trade:
Leave the esophageal tube in.
Reattempt endotracheal intubation.
"When life gives you lemons, make lemonade."
If the endotracheal tube is in the esophagus, do NOT take it out! You have just created a conduit to remove further bleeding from the field. Take another look with Yankauer suction. Reattempt your intubation with a second tube. Do this as soon as you recognize an esophageal intubation to reduce the patient's risk for oxygen desaturation.
Note:
- Be sure that the esophageal tube is turned away from the providers to avoid being splashed with blood.
- Have an assistant suction the proximal port of the esophageal tube when blood starts pouring out of it.
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Sign in nowIt can give us an idea of where the trachea is in relation to the tube. The trachea should be anterior, so if the next tube placed is not anterior to the one in the esophagus, maybe the one we thought was in the esophagus was not in the esophagus (it still might not be in the trachea), or the new tube is not in the trachea.
Directing the esophageal tube into a red bag, or a towel that is rolled up, can be one way to avoid having blood/vomit flying all over the place.
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Kudos to Dr. Scott Weingart for bringing this (http://emcrit.org/blogpost/ett-as-suctio/) nifty little contraption to my attention for those REALLY wet airways. Like "the patient just finished drinking his liter of PO contrast and then coded" sort of wet.
Yes, that Ryan on EM Lit of Note is full of surprises! The endowed chair has already been an exciting experience and I don't even official start the position until July!