Medical Scenario #1 

Important Reminder: 

These are hypothetical situations and are not meant to be taken literally. Always follow your hospital's policies, procedures, and guidelines. Your hospital will have specific guidelines that you must follow in each department. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on patients. 

SCENARIO:  

You are called to the NICU by an RN to assess a 2 kg intubated baby that has been desaturating and has had more frequent bradycardic episodes. The baby lying in the radiant warmer, but the patient’s position looks to be very crooked in the bed. The ET tube is secure at 6 cm at the lip. The babies color looks a bit blue centrally and the SPO2 is 60% on 80% FiO2. 

& DISCUSS: Since the baby is having more frequent desaturations and bradycardias, what are some immediate actions we may

want to consider? 

ANSWER: Before we troubleshoot what is wrong, we want to first take care the oxygenation issue. You want to consider increasing the fio2 or possibly doing PPV if increasing the fio2 does not get the SpO2 into the normal range. Prolonged desaturation can lead to tissue death and potential long-term complications. Next, we want to check the patency of the ET tube and the placement of the ET tube immediately. We can achieve this in a few different ways. We want to start with the actions that can be done immediately. We look at the ventilator waveforms and we notice there are no inspiratory and expiratory tracings. We ask an RN to retrieve a colorimetric capnometer as we auscultate the lungs. There are minimal breath sounds noted. The colorimetric capnometer reveals no color change. You see no condensation in the ET tube when the baby takes a breath. You also notice the ET tube is at 6cm at the lip on a 2 kg baby. With the NRP recommendation for ET tube placement, the ET tube should be at approx. 8cm at the lip. 

ACTION: Since the patient's vital signs are unstable and multiple assessments have shown the ET tube is not properly placed, the ET tube should be removed as this patient has somehow become extubated. PPV should immediately be continued. The provider should be immediately notified, and a plan should be constructed with your provider. Some patients may not require reintubation but that is up to the provider. 

SITUATION: You remove the ET tube and provide bag mask ventilation while the provider is notified. A discussion with the physician is held and you determine the   baby is too sick to maintain adequate ventilation on its own so the baby must be reintubated. You have a colleague gather your intubation supplies at the bedside and prepare for reintubation. 

ACTION: You attempt intubation but cannot visualize the vocal cords on the first attempt. You notice a large amount of secretions while attempting intubation and there the baby is fighting you very much during the attempt making it extremely difficult. 

& DISCUSS: What are some things you may want to consider doing to increase the chances of successful intubation?  

ANSWER: You may want to obtain a larger bore suction catheter to clear any thick secretions in the oropharynx. A smaller bore suction catheter will clog easily and may not be helpful. Be careful not to pass a large bore suction catheter through the nares as this can cause trauma. You may want to ask the physician to order sedation for the patient. Intubation can be difficult with a fighting patient. Sedation may also help with the patency of the airway. 

ACTION: The mouth is suctioned with a larger bore suction catheter and an RN gives dose of fentanyl. The baby is now more relaxed, and intubation should be easier. A second intubation attempt is unsuccessful, and you now ask another colleague to come try to intubate the patient. After 2 more unsuccessful attempts, the physician is called. The physician trusts that this may be an extremely difficult airway to obtain. 

& DISCUSS: Describe a few different options we may consider at this time. 

ANSWER: 

 1. We may want to consider using a Laryngeal Mask Airway (LMA). This can take place of the ET tube and does not require direct visualization. Even though LMAs are not recommended for long term use, there are occasions where it may be necessary. 

 2. We may want to see if there is a video laryngoscope available for use. Video laryngoscopy may allow easier, less traumatic intubation. See if your hospital has a policy and equipment for video laryngoscopy. 

3. You may want to consider trying the patient on a non-invasive mode of ventilation. The baby may be able to maintain ventilation without reintubation and mechanical ventilation. 

4. If the provider decides that the patient must be reintubated and video laryngoscopy is not available, continue trying to intubate the patient, switching off every 2 failed attempts with a person skilled in intubation. Make sure to reposition the patient after each attempt.  If patients vitals become unstable, stop intubation and provide PPV via mask and O2 to maintain appropriate SpO2.

Key Takeaways:

• Always take care of the patient first in high risk scenarios. Once the patient is stabilized, you can then troubleshoot the situation.

• Intubation may not always be possible. Make sure you this ahead and have a second and third plan if intubation is unsuccessful.

• Learning how to ventilate a baby with a flow inflating mask can mean the difference between life and death. Make sure you practice regularly on a mannequin, ensuring the airway is open, the mask is appropriately sized, the patients position is optimal, and there are no obstructions. Become a master at this task and you will feel much more confident in delivery scenarios.

Important Reminder: 

These are hypothetical situations and are not meant to be taken literally. Always follow your hospital's policies, procedures, and guidelines. Your hospital will have specific guidelines that you must follow in each department. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on patients.