A 65 yo M is rushed into the resus room. He is pale and is vomiting a mixture of coffee ground emesis and bright red blood. His vitals are stable currently but he is continuing to vomit in the emergency department. This patient requires a definitive airway. You have studied the emcrit guidelines for intubating the GI bleeder but cannot pass a NG tube, so you decide to proceed with intubation.

 

After RSI you open the mouth and see copious amounts of blood and GI contents. You and your assistant are attempting to suction but cannot clear the airway. You see nothing.

 

This sphincter-tightening situation can happen to you despite your best efforts. However there are whispers of a new technique that may help visualization in this exact situation. Why not intentional intubate the esophagus and inflate the cuff? This has been described in case reports from the anesthesiology literature. The wider bore ETT can allow for improved suction and removal of gastric contents from the airway clearing up your view. Placing an ETT in the esophagus is much easier than a flimsy NG tube and is not long enough to come close to possible varices. Even better, if you place it incorrectly the worse thing that happens is that you intubate the patient. This may not be ready for prime time but should hopefully spark some discussion.

 

Sorour K, Donovan L. Intentional esophageal intubation to improve visualization during emergent endotracheal intubation in the context of massive vomiting: a case report. Journal of Clinical Anesthesia. 2015;27:168–169

Milne B, Burjorjee J. A potential method for safe recovery from recognized inadvertent esophageal intubation. The Open Anesthesiology Journal. 2013;7:15-18.