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Emergency Ultrasound for the Detection of Esophageal Intubation

2010; Wiley; Volume: 17; Issue: 4 Linguagem: Inglês

10.1111/j.1553-2712.2010.00690.x

1553-2712

Beatrice Hoffmann, John P. Gullett,

Cardiac Arrest and Resuscitation

A 63-year-old female was brought to the emergency department (ED) by ambulance for suspected acute stroke. The patient had a complex medical history including sickle cell anemia with prior vasoocclusive crisis, hypertension, gout, pancreatitis, and congestive heart failure. She was transferred from a longitudinal care center where she was recovering from a left lower extremity deep vein thrombosis, thought to be caused by venous occlusion secondary to her sickle cell anemia. She had reported some vague headaches over the past few days, and on the day of presentation experienced a thunderclap frontal headache and transient bilateral acute vision loss. Her nursing home staff activated emergency medical services and she was transported to the ED within an hour of symptom onset. Here, she was hemodynamically stable with no current neurologic deficits, but had persistent frontal headaches. An emergently performed computed tomography scan of the head showed a small subarachnoid hemorrhage in the frontal vertex with adjacent brain tissue edema but no mass effect. The patient was admitted to the neurology intensive care unit for suspected small cortical vein thrombosis with hemorrhage and emergent exchange transfusion for sickle cell crisis. While awaiting admission and further diagnostic testing, she suffered a generalized tonic–clonic seizure. Her postictal state was characterized as a significantly depressed mental status with a Glasgow Coma Scale score of 8. The decision was made to proceed with endotracheal intubation and assisted ventilation for airway protection. The patient was preoxygenated with assisted bag-valve-mask ventilation and 100% supplemental oxygen. Cricoid pressure was applied, and rapid sequence intubation was initiated with etomidate and succinylcholine. Simultaneous with the intubation preparations, a bedside ultrasound was performed by a separate medical provider. Before endotracheal tube (ETT) insertion, a high-frequency linear ultrasound probe was placed transversely at the anterior aspect of the neck at the level of the thyroid lobes (Figure 1). The esophagus was identified as an oval multilayered structure immediately to the left of the trachea and posterior to the left thyroid lobe (Figure 2). Endotracheal intubation was then attempted by one of the treating physicians. The Cormack and Lehane laryngeal view was determined as grade III, which is classified as “difficult.” During the first ETT intubation attempt, sonography directly observed the ETT being inserted into the esophagus (Figure 2 and Video Clip S1, available as supporting information in the online version of this paper). The intraesophageal ETT was immediately removed and a second intubation attempt was initiated. The second attempt was also followed by real-time sonography, now visualizing an empty esophagus throughout the procedure and observing a brief “flush” of movement and hyperechoic artifacts at the anterior aspect of the trachea during tube insertion (Video Clip S1). Lung ultrasound showed bilateral equal lung sliding suggesting correct tube position within the trachea. Physical examination and auscultation revealed fogging of the ETT, positive color change on carbon dioxide colorimetry, and bilateral, equal breath sounds. A subsequent chest x-ray showed correct ETT position and bilateral inflated lungs. The patient remained stable with pulse oxygenation at 97% during the procedure and was hemodynamically stable. A linear high-frequency transducer is positioned over the anterior neck below the larynx for detection of endotracheal or esophageal intubation. Ultrasound images captured. The left image shows a transverse sonographic view of the midanterior neck including the left lobe of the thyroid (asterisk), the trachea (thick white arrow), and the empty esophagus (thin white arrow). The right image shows a foreign body within the esophagus casting a shadow (thin white arrow). In this case of a patient with difficult laryngeal view requiring emergency airway, bedside ultrasound performed during ETT insertion detected esophageal intubation in real time. Bedside ultrasound could assist in defining correct ETT position in the future. Video Clip S1. Ultrasound and esophageal intubation. This video clips is in QuickTime. Please note: Wiley Periodicals Inc. is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.