Survival after massive bleeding into the airway in a patient at risk from "can't intubate, can't ventilate".

A patient survived massive bleeding into the airway due to blowout of the right internal jugular vein associated with a failed free-flap graft for pharyngeal malignancy. A recently decannulated "covering tracheostomy" could not be easily re-established. Direct laryngoscopy and mask ventilation were inappropriate because the pharyngeal mucosal wound opened spontaneously and progressively and bleeding was dramatic. Positive pressure ventilation via a facemask risked widespread surgical emphysema and further wound disruption and because bleeding was from the internal jugular vein, there would also have been a risk of air embolism. The clinical situation evolved rapidly so time management and consideration of hierarchy of mortality risks was critical. It was eventually possible to re-establish the previous tracheostomy site as a result of close co-operation between the surgical and anaesthetic teams. In difficult intubation where the problems are anticipated, the notion of responsive contingency planning is suggested to be of more general relevance than the current standard of considering alternative fallback options. The limitations of conventional capnography in this situation are also noteworthy.