Case 18: A Tracheostomy Is Urgently Needed and You Have Never Done One

Abstract

It is late at night in a medium- to large-sized hospital in Morocco. You, the only anesthesiologist on call in the hospital, are called to the emergency room where you find a 52-year-old woman with her neck and face severely swollen. The cause is an anaphylactic reaction of unknown origin. Several doses of epinephrine have been given but the patient is now unresponsive with shallow rapid and labored breathing. She is receiving oxygen at 15 l/min via a non-rebreather. Her oxygen saturation is 86% and is trending downward. Listening to her chest, you hear very little air entry. You get an Ambu bag and assist ventilation with 100% oxygen. There is no improvement. You attempt to intubate the trachea with a Mac 3 blade but see nothing. You feel that succinylcholine will not be helpful as the patient is now relaxed and completely unresponsive. A two-person mask ventilation with a large oral airway is unsuccessful. The LMA, which you have called for, has not arrived. The neck is so swollen that you dismiss the use of a cricothyrotomy. You request a nurse to bring you a tracheotomy set. You are told that an ENT specialist is called for but he can only be there in 30 min. The oxygen saturation is now 76% and there is a dramatic decrease in the patient’s pulse rate and blood pressure. You have seen many tracheostomies being performed, but you have never done one on your own and especially not under these circumstances. But you feel this is the only option for this woman. You grab the scalpel and feel a great sense of insecurity and dread, but you have committed yourself.