Topic: Simulation Debrief – Airway Management in the CT Scanner
Host: Dr. Houman Khosravani
Guests: Dr. Nicole Kester-Greene, Lowyl Notario (APN), Miranda Lamb (Clinical Educator, now our *stellar* Patient Care Manager for our ED!)
Patient: 67-year-old presenting with full Left MCA syndrome (Right hemiplegia/aphasia).
History: Hypertension, Diabetes, on Ramipril (ACE Inhibitor).
Initial Action: CT Head (Aspects 7, no hemorrhage) $\rightarrow$ tPA administered in the CT scanner.
The Complication: Post-tPA, the patient developed hypoxia (sats low 90s) and significant tongue/lip swelling.
Note: Angioedema can be precipitated by the combination of tPA and ACE inhibitors.
The team discussed the critical decision-making process when a "Code Stroke" turns into a "Code Airway."
Immediate Treatment:
Epinephrine: The team opted for 0.5 mg IM Epinephrine.
Debate: There was a discussion regarding IV vs. IM Epi. The consensus was to avoid IV bolus Epi in a stroke patient (due to hypertension risks) unless hypotensive, sticking to IM for the allergic reaction while monitoring BP.
Adjuncts: Methylprednisolone (125 mg) and Benadryl (50 mg).
Airway Strategy:
The Challenge: Assessing whether to intubate immediately or observe. Given the progression, the decision was to intubate.
The Method: Awake Intubation (using Ketamine/Lidocaine/Phenylephrine) was chosen over RSI (Rapid Sequence Intubation) to avoid cardiovascular collapse and maintain spontaneous respiration in a difficult airway.
The debrief heavily focused on Human Factors and inter-departmental communication.
The "CT Trap": The patient was isolated in the scanner. Managing an airway in the CT control room/scanner is dangerous due to lack of space and equipment.
The Move: A critical decision was made to move back to the ED Resus room.
Communication Gap: There was confusion regarding where the patient was going, highlighting the need for closed-loop communication before moving a critical patient.
The Transition: The Stroke Team leader initially managed the code but recognized the need to hand over the airway to the EM physician.
Explicit Handover: The importance of clearly stating, "I am handing over the airway to you," to avoid the "two cooks in the kitchen" scenario.
Dr. Kester-Greene introduced a specific communication framework to align the team during chaos:
Initial Summary: When the team arrives (Status, Diagnosis, Treatment so far).
Priority Summary: Mid-resuscitation (Re-evaluating what is most important right now).
Pre-Transfer Summary: Before moving the patient (Where are we going? Do we have the right equipment?).
"Speaking Up": The nurse noted early signs of anaphylaxis but felt unheard initially.
"Listening Up": Leaders must create space for team members to voice concerns (e.g., "Does anyone see anything I missed?").
The group established that for future cases involving angioedema in the scanner:
Secure the Airway: If imminent failure, manage on-site (or immediate vicinity).
Stable but Concerned: Transport immediately to the Resus room where equipment and space are optimized.
Clear Terminology: Use "Airway Emergency" to trigger the correct mindset shift from "Stroke Protocol."
Dr. Houman Khosravani – Stroke Physician
Dr. Nicole Kester-Greene – Director of Emergency Dept Simulation
Lowyl Notario – Advanced Practice Nurse / Patient Care Manager
Miranda Lamb – Interim Clinical Educator--> Now our Stellar Patient Care Manager
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