HCMC_P_049062 - Hennepin County Medical Center

Case Reports
laryngeal mask airway (LMA) was developed in the
1980s and initially used in the operating room as an
alternative to bag-valve-mask (BVM) ventilation. It
has become a popular airway adjunct in the
emergency setting for the management of difficult
airways. The intubating LMA (ILMA) was developed
in the late 1990s and allows an endotracheal tube to
be passed through the LMA.
Placement of the ILMA is a simple, single operator
procedure: (http://www.hqmeded.com/video/
13164204). The ILMA cuff is checked for leaks. The
cuff is then deflated against a flat surface. A water
soluble lubricant should be applied to the posterior
surface of the mask. The ILMA is inserted, while
holding the handle, into the oropharynx against the
hard palate, with the mask opening toward the
tongue. It is advanced until resistance is met, and the
cuff then inflated. The handle can be held like a
skillet, and lifted toward the ceiling, to insure an
adequate seal of the mask. The BVM is directly
attached to the ILMA. Either an ETT or the Fastrach
Silicone Tube (FTST, a tube specially designed for
intubation through the ILMA) can be used. At
Hennepin, a standard ETT is often used. Placement
of this is facilitated by inserting the tube with the
curvature opposite of how it is held during standard
intubation. A stabilizer rod is used to maintain the
ETT in position, while the ILMA is deflated and
removed from around the ETT. McGill forceps can
also be used to stabilize the ETT in the oropharynx
as the ILMA is removed.
As illustrated in this case report, the ILMA is an
easily placed airway adjunct that can be used in the
management of difficult airway in the emergency
department. An important learning point from this
case is ensuring that the stabilizer rod is removed
temporarily to allow passage of the pilot balloon for
the ETT. On the first attempt at removal of the ILMA
around the ETT, this was not done, and ultimately
resulted in dislodgement of the ETT. On the subsequent
attempt, this was performed and the ILMA was
removed from around the ETT without difficulty.
Overall, the use of the ILMA was instrumental in
avoiding a surgical airway in this patient.
A Memorable Case of Hypothermia
by Ernie Ruiz, MD
Ernie Ruiz, MD
Founding member of
Emergency Services
Hennepin County Medical Center
A young woman was found by police laying on the
sidewalk of a Minneapolis city street on a very cold
morning in midwinter in 1975-1976. She was cold
and appeared dead. The city's morgue vehicle was
summoned. While awaiting the van, the woman took
a breath. The ambulance was summoned and the
patient was delivered to the Hennepin Emergency
Department. She was without a pulse as she was
transferred to the resuscitation cart. An ECG monitor
showed ventricular fibrillation. While the patient was
being prepared for resuscitation, I called Dr. John
Haglin, Head of Cardiovascular Surgery (CVP),
because during my surgery training he and I
discussed the possibility of using a heart lung
machine to warm very cold patients. Dr. Haglin
agreed that this patient was a good candidate. He
called Dr. Per Wickstrom, who was his Chief
Resident on CVP, and the patient was moved to the
operating room. On the heart lung machine, the
patient warmed to normal temperature in just a few
minutes. She was able to go home in a few days.
She was normal again.
This was the first time that this method of re-warming
was used and reported. It quickly became the world
standard for severe hypothermia resuscitation. This
was a world's first for Hennepin.
8 | Approaches in Critical Care | January 2013