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A 56-year-old male was the driver of a motorcycle involved in a motor vehicle crash. The primary survey performed by the trauma team reveals the patient to have a patent airway, with spontaneous breathing and clear, bilateral breath sounds. His circulation is normal with strong pulses present in all limbs and no signs of external hemorrhage. His Glasgow Coma Scale is 14 of 15 due to slight confusion. Secondary survey reveals rib fractures on the left and several orthopedic injuries including a broken tibia and femur on the left as well as a pelvic fracture. Several hours after the injury, the patient is brought to the operating room (OR) for surgical repair of the long bone fractures and external fixation stabilization of the pelvic fracture under general anesthesia.

He is admitted to the ICU immediately after the surgery, and is extubated uneventfully shortly thereafter. For the first 2 days after the injury, the patient has required high doses of opioids to control his pain from the rib fractures. Late in the evening of the third postoperative day, he spikes a temperature of 38.9°C, and is having trouble clearing his secretions with coughing. His respiratory rate is 32 per minute; his oxygen saturation is 92% on a non-rebreather face mask (NRM); his heart rate is 120 beats per minute and his blood pressure is 160/85. He is complaining of dyspnea and severe pain. The patient looks tired and has obvious use of accessory muscles of respiration. A chest radiograph reveals volume loss and airspace disease with air bronchograms in the right lower lobe but no pneumothorax.

The house staff is alerted by the patient's nurse. A first-year resident is on call with a senior fellow in critical care medicine (CCM). After their assessment and discussion with the attending staff by telephone, the house staff team proceeds with endotracheal intubation. Based on the examination of the airway, no difficulties are anticipated with the tracheal intubation itself. The respiratory therapist prepares the usual equipment while oxygen is administered by NRB. The resident physician administers 2 mg of midazolam and with the patient placed in semi-Fowler position at 45 degrees, makes an attempt at intubation using direct laryngoscopy (DL) under the supervision of the senior fellow. The first attempt results in an esophageal intubation. Oxygen saturations dip into the high 80s. After repositioning the patient's head and neck, and recovery of the saturations into the low 90s this time employing a bag-mask unit with high-flow oxygen, a second attempt is performed by the resident. Despite using a tracheal introducer (also known as “gum-elastic bougie”) and the BURP maneuver, the attempt is again unsuccessful.

A third attempt at tracheal intubation is made by the CCM fellow following the administration of propofol 100 mg and succinylcholine 120 mg, but this also fails. After this intubation attempt, it becomes more difficult to manually ventilate the patient using bag-mask. ...

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