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cykes02

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  1. I'm perplexed by your post. The first thing I can offer is yes, it was probably dumb luck that your nasotracheal intubation attempt of an apneic patient was successful. That being said, good for you. You thought outside the box and improvised when conventional measures failed. Was it contraindicated? Yes, but I would argue only relatively. If the goal is to optimize oxygenation, which it is, you succeed. Two questions remain. The first is for your service: why isn't your surgical airway kit with the rest of your advanced airway equipment? You just learned a hard lesson and that is you cannot always predict the failed airway. You can assume a difficult airway, which you did, but did not have the appropriate equipment prepared when you needed it in a hurry. The second question is a physiological one: why was this patient clenched? Trismus is normally associated with muscular contraction, which should cease actor shortly after the time of cardiac arrest. Paralytics used in RSI should provide no benefit in the case of arrest because the patient should already be relaxed as muscles cannot contract without oxygen (for very long) and oxygen is not supplied without circulation, nor is carbon dioxide eliminated, which will further, indirectly, lead to the absence of a muscular contraction. Yes, I'm aware that there is a lot more that goes into the function of skeletal muscle but that's beyond the scope of this comment. My only other comment, and you may have just not mentioned it, is don't forget the basics. A nasal airway and a BVM make a very effective bridge to definitive airway placement in the clenched patient, in most cases assuming the absence of secretion or emesis and an adequate mask seal. I'm sure you thought of it but never neglect oxygenation for the purpose of airway placement. The airway does nothing to affect outcome if we allow hypoxia, especially prolonged hypoxia, in the interim.
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