County EM - EM-Critical Care -ludwing-angina-airway-management

EM-CCM Presentation Review 09/16/2020

Authors: Keesandra Agenor MD, John Riggins Jr MD

Edited by: Raymond Beyda MD, Eden Kim DO

Case

A 74-year-old male with PMH of hypertension and dyslipidemia presents to the ED with acute tongue swelling, neck swelling, and changes in his voice that started the prior evening. He has had several weeks of a right-sided toothache and recently went to see the dentist yesterday who discharged him on amoxicillin.

Physical exam

Temp 98.6 F BP 186/94 mmHg HR 125/min RR 22/min O2sat 100% on RA

General: elderly gentleman sitting up in bed, mild respiratory distress

HEENT: bilateral swelling of submental and submandibular regions, elevated floor of mouth with induration

Pulm: notable stridor

CVS: tachycardic

Abd: soft, non-tender, not distended

Skin: warm, well-perfused

Neuro: appears confused but following some commands

Figure 1: “Double Tongue” Appearance in Ludwig’s Angina [1]

Diagnosis:

Ludwig’s Angina

Definition of Ludwig’s Angina:

Bilateral inflammation of the sublingual, submental, and submandibular spaces precipitated by infection of the teeth, oral lesions, or injuries [2]

Management of Ludwig’s Angina: [3]

1. Intubate – Call appropriate airway management specialists (anesthesia, ENT), if available, to perform in OR; have “cric kit” at bedside with neck marked and prepped; have analgesic and sedation medications available, avoid paralytics if possible, make sure to preoxygenate, have your airway adjuncts at the bedside (ie LMA, bougie, OPA, NPA)
2. IV antibiotics +/- dexamethasone, nebulized epinephrine
3. Exploration in the operating room

Patients with Ludwig’s angina have an anatomically and potentially physiologically complex airway that can quickly become compromised.

Assessment of airway: [4]

Look for external markers of difficult intubation: body habitus, head/neck (short neck), mouth (small opening, loose or prominent teeth), jaw (malocclusion).

Evaluate 3-3-2: can the patient fit 3 fingers between incisors? Is the mandible length 3 fingers from the mentum to the hyoid bone? Is the distance from the hyoid to the thyroid 2 fingers apart?

Mallampati: Class I/II adequate oral access, III moderate difficulty, IV high difficulty.

Obstruction: epiglottitis, head/neck CA, Ludwig’s angina, neck hematoma, foreign body, thermal injury or anything that compromise laryngoscopy, passage of the ETT, or BMV ventilation.

Neck mobility (slight extension of the neck in the sniff position – optimal laryngeal view): trauma (c-collar), elderly (arthritis), Down Syndrome (atlantoaxial instability).

In a small, prospective study performed in the UK, the use of an airway assessment score based on the LEMON criteria can risk-stratify difficult intubations accurately in the ED. Patients with a higher airway assessment score were more likely to have a poor laryngoscopic view in comparison to those patients with a low airway assessment score. [4]

Definition of a difficult airway: [5]

– 3 attempts or more needed to establish a secure airway

– 10 minutes or greater are needed to establish a secure airway

– High airway assessment score using LEMON criteria

Role of awake fiberoptic intubation in the difficult airway: [6]

– Used in patients with anticipated difficult airways

– Mitigates risk of endotracheal intubation with induction of general anesthesia including: inadequate ventilation and oxygenation, loss of upper airway patency, and failed intubation attempts

Figure 2: Fiberoptic scope [7]

Figure 3: View of the fiberoptic scope screen with visualization of vocal cords and trachea

Remember that a supraglottic airway can be used temporarily if the initial attempts at an endotracheal intubation have failed (i.e. laryngeal mask airway).

Steps in awake fiberoptic intubation: [8,9,10]

1. Prep the patient (Sedating medications, topical/IV analgesia, pre-oxygenation)

Drying of secretions:

Glycopyrrolate 0.1-0.2 mg IVP

Atropine 0.5- 1mg IVP

Prevention of nausea and vomiting/blunting of gag reflex:

Ondansetron 4 – 8 mg IVP

Common topical anesthesia methods:

-Nebulized lidocaine: 8 cc of 2% lidocaine nebulized @ 5 liters per min

-Viscous lidocaine: swishing in back of mouth with 2% viscous lidocaine

-Mucosal Atomizer Device: spray 2% lidocaine via device above trachea, around cords and into nares

Pre-oxygenate with non-rebreather and nasal cannula

Sedating medications:

Midazolam, ketamine, propofol, etomidate, dexmedetomidine

Ketamine-facilitated intubation can be used in fiberoptic intubation; however, it is different from awake intubation, where a patient is able to cooperate. Ketamine-facilitated intubation results in dissociation, which makes a patient unaware of their surroundings and is associated with a 0.3% risk of laryngospasm [11]. Ketamine is not the most popular sedative in awake intubations; however, it can be used as an alternative approach to the RSI approach if the patient cannot tolerate awake intubation. As with all steps in the management of the difficult airway, be prepared for RSI, an alternative approach, if Ketamine-facilitated intubation fails.

2. 2. Prep the equipment: lubricate the endotracheal tube and thread it over the fiberscope

3. 3. Use fiberscope via nasal or oral approach and look for the entrance of the epiglottis

4. 4. Confirm tube placement via direct visualization of endotracheal tube passing the epiglottis, auscultation of breath sounds, waveform capnography

5. 5. Secure the tube in place

Operator experience in fiberoptic intubation: [12]

Risk in a difficult airway progressing to a failed airway increases with multiple attempts. The key in management of the difficult airway is anticipation, preparation, and performance of fiber optic intubation by an emergency physician that has reached a proficiency skill level or an anaesthesiologist. Simulation can be an effective tool to train residents to reach fiberoptic skill proficiency level and maintain it through re-training.

Figure 4: Managing procedural complications during awake tracheal intubations [13]

If all else fails during a difficult intubation, proceed to cricothyrotomy. Try to mark out landmarks as shown below in Figure 5. If landmarks are unable to be visualized, ultrasound can be used to identify landmarks if the patient is stable. [14] In an unstable patient where landmarks cannot be identified, make a vertical incision into the midline of the neck until landmarks can be visualized.

Figure 5: Cricothyrotomy Landmarks [15]

Case Summary:

The patient is taken emergently to the operating room by anesthesia and ENT. The patient is intubated successfully via nasal fiberoptic approach. The patient is transferred to the surgical ICU for further management of his Ludwig’s angina. The patient required vasopressors and broad-spectrum antibiotics for septic shock. The surgeons diagnosed necrotizing fasciitis, and the patient required multiple operations for debridement and drainage of his face and neck.