2016 FSA Posters

P033: PILLAR HOLDING YOU UP?
Ezekiel J Anderson, DO, Hernando DeSoto, MD; University of Florida-Jacksonville

Introduction: The Glidescope® is useful in difficult intubations.  The angled blade improves visualization of the epiglottic tip and vocal cord in Cormack/Lehane classification Grade 3 and 4 airways facilitating the intubation of these difficult airways.  When used properly the Glidescope® can facilitate intubation and decrease chances of injury.   The device can also cause injury when not handled correctly.

Background: A 33-yr-old male presented for left leg laceration and a vascular injury following a motorcycle crash. Preoperative physical examination revealed an extremely intoxicated and uncooperative patient making airway assessment difficult, which was further complicated by a Miami J collar. 

Anesthesia was induced following preoxygenation via rapid sequence induction.  Head alignment was maintained in a neutral position and gentle cricoid pressure was applied. Following easy insertion of a Glidescope® video laryngoscopy number 3 blade and obtaining a Grade I view of the vocal cords the patient was intubated with a 7.5 single lumen cuffed endotracheal tube over the manufacturer recommended Rigid Stylet™.  The cuff was inflated and positive pressure ventilation was initiated.

Following uncomplicated repair of crash related injuries the patient’s orogastric tube appeared to contain a small amount of blood and additional bleeding was noted on preparation for extubation with pharyngeal suctioning.  At this point the Glidescope® was used for evaluation of the origin of the blood in the airway and upon insertion of the Glidescope® the tracheal tube was seen perforating the right anterior tonsillar pillar. The Oral MaxilloFacial Surgery (OMFS) was immediately consulted and the evaluation noted an injury to the anterior tonsillar pillar that was hemostatic and not currently bleeding.  The cuff of soft tissue formed by the pillar was tied off, incised and cauterized which allowed the endotracheal tube to be removed from the patient without any further issues. Minimal throat soreness was reported on postoperative day one.

Discussion: Blind advancement of the endotracheal tube is a common factor associated with intraoral injuries when intubating the airway with the Glidescope®. Injuries have occurred despite perceived smooth and easy intubations. Upward forces applied to the Glidescope® to achieve laryngeal visualization may stretched taut the pharyngeal pillars and surrounding tissues making them susceptible to perforation. Glidescope® recommends direct visualization of the patients mouth and to hug the tongue as the tube is advanced. The rigid stylet and endotracheal tube can be placed with tip at base of tongue parallel to the blade or perpendicular and then once visualized on screen rotated into place.   Constant and direct visualization of the tip of the endotracheal tube during advancement into the oropharynx is key to not traumatizing airway anatomy.

Conclusion: The Glidescope® video laryngoscope is a useful tool for intubation. It improves glottic view and reduces the need for airway manipulation. Despite its ease of use, thorough understanding of its unique characteristics is important in avoiding potential intubation injuries.