Difficult Airway Scenario

What are your first actions?

You state to the patient you are getting some adrenaline ready as you think she is in anaphylaxis. She is unable to talk back but nods and points to her handbag. You can see the patient is starting to really panic and looks like she is gasping for air. You find an EpiPen in her handbag. 

You have already drawn up your own IM adrenaline but think the EpiPen will be easier to administer as it is fast. Which one should you give? 

You give your own drawn up adrenaline as the EpiPen may only contain 300mcg of Adrenaline 1:1000 compared to your 500 mcg dose. You notice the patient is still deteriorating as you are giving it, and she now looks very pale in colour. 

What other actions should we try to perform? 

The patient’s friend is still present and gratefully helps you to lie the patient down and connect your cables for observations, understanding your clear instructions, whilst you look at your 02 administration and airway. You start to hear a loud snore and the angioedema you noticed when first meeting the patient, seems to have got worse. 

What is your next priority? 

As you investigate their airway you see severe swelling and are immediately concerned. You are an intubating paramedic so have that skill in your arsenal. Even though you expect the patient will deteriorate very soon, she is still GCS 15. 

What may be the most appropriate airway manoeuvre at this point? 

It has been 2 mins since you have given your IM adrenaline, when can you give your next dose for anaphylaxis?

You are still unhappy with the airway and the risk of losing the patency is increasing. The patients GCS starts to drop. You are aware that early intubation is potentially necessary to secure an airway in anaphylaxis, so you start to prepare your equipment.  

Ideally, how many people are required for intubation attempts? 

Thankfully, the crew that was backing you up has arrived. The patient has just gone into cardiac arrest. The crew start ALS as you try to gain an airway. You look at intubation and see a grade 4 view on the Cormack-Lehane scale. What does this mean?

You retract as the airway looks too difficult to even attempt intubation. You try to ventilate the patient with a BVM but are getting very minimal and ineffective air movement. What techniques could you use to maximise the chances of upgrading your view during intubation?

You try all the techniques above but have no improvement on your view and are worried the swelling in the airway is getting worse and worse. What would be your next steps in gaining an airway?

You start to get your FONA equipment ready as you fear the patient’s airway is about to close imminently. You successfully gain a FONA airway and are now able to ventilate the patient.  

What other treatment priorities should be considered in cardiac arrest caused by anaphylaxis? 

On your fourth rhythm check and your second dose of adrenaline, you have a ROSC. What should be our next steps for patient management?

You gain a blood pressure of 85/54 mmHg. What is the systolic you must aim for in a ROSC patient in this scenario?

You already have fluids running and consider adrenaline 1:10000 to increase you blood pressure. What is your initial dose you are able to administer?

What medication can you use to increase a patient’s heart rate if bradycardic post ROSC?