HCMC_P_049062 - Hennepin County Medical Center

Case Reports
Figure One. The C-MAC videolaryngoscope. The camera is fixed
in the handle, with the lens within the blade. Images are projected
onto a video screen that allows others besides the intubator to
view the anatomy during the intubation procedure. Its usefulness
is demonstrated in a case of difficult boogie placement, seen at
http://www.hqmeded.com/video/40879557
invaginated scolex is clearly seen inside of the cystic cavity.
T = 124 minutes: She began to cough against the
vent and was, therefore, paralyzed with vecuronium.
An ABG revealed a mild acidosis with a pH of 7.19.
Her EKG showed sinus tachycardia with lateral
t wave inversions, concerning for demand ischemia.
T = 164 minutes: The patient was taken to CT
scanner for a CT of the neck with IV contrast to rule
out Ludwig’s angina. Her CT showed a massively
swollen tongue filling the airway and protruding from
the mouth, with significant narrowing of the airway.
There was only mild swelling of the sublingual and
submandibular areas, suggesting that angioedema
was more likely the cause of swelling than a soft
tissue abscess.
T = 184 minutes: She was transferred to the MICU
with a secure airway.
The patient’s benazepril was discontinued. Serial
troponins were followed, given her abnormal ECG
post -intubation and the witnessed episodes of
bigeminy and ventricular tachycardia during
intubation attempts. Her troponin peaked at 0.193
ng/mL. Transthoracic echocardiogram showed a
normal left ventricular ejection fraction, but she was
noted to have an area of hypokinesis in the mid
portion of the intraventricular septum, concerning for
atypical stress cardiomyopathy.
On hospital day 2, the patient had significant
improvement in her tongue swelling. Given her
extremely difficult intubation in the emergency
department, she was extubated over an exchange
catheter with anesthesia at the bedside. She
tolerated extubation well. She was transferred to the
medicine floor and discharged the next day. She was
instructed to discard her amlodipine- benazepril
combination pills at home, and given a new
prescription for amlodipine alone. She was advised to
avoid ACE inhibitors and an allergy alert was placed
in her chart.
Discussion
Two important airway adjuncts were used in the
management of this difficult airway. The C-MAC
videolaryngoscope (Figure One) uses a modified
Macintosh laryngoscope blade with an integrated
video camera, which is directed toward the blade tip.
More details of its functions and an example of its
usefulness are illustrated in a video that shows
difficulty passing a boogie. See http://www.hqmeded.
com/video/40879557. The video screen image allows
the attending physician to visualize the airway as the
resident is intubating (see video). It also allows for
recording of the intubation to facilitate image review
and teaching opportunities. Studies have demonstrated
a greater proportion of successful intubations and a
greater percentage of Cormack-Lehane grade I or II
views when compared with direct laryngoscopy.
Figure Two. The intubating laryngeal mask airway (ILMA). The
procedure for its placement can be viewed at http://www.hqmeded.
com/video/13164204.
The ILMA (Figure Two) is a supraglottic airway device
that is useful for difficult airway management. The
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