1. MORBIDITY & MORTALITY Trey Bates, M.D.

2.  54 y/o man with advanced squamous cell carcinoma of the larynx  S/P radiation therapy and chemotherapy  Developed significant radiation fibrosis not responsive to medical tx with Trental (pentoxifylline) or Botox  Extreme contracture of neck with limited extension

3.  Unable to tolerate neck extension  Dysphagia and weight loss; PEG tube inserted  Scheduled for lysis of SCM muscle to release adhesions and an esophageal dilation and esophagoscopy for dysphagia  Difficult Airway and previous difficult awake fiberoptic intubation

4. Several attempts at previous awake fiberoptic intubation were unsuccessful Right nasotracheal intubation attempted ETT not anle to be passed beyond vocal cords Bleeding occurred and procedure aborted

5. Pt seen in holding area Consents reviewed and signed Given 1mg Versed for anxiolysis and an additional 1mg given as nasal trumpets inserted Nasal trumpets coated with viscous lidocaine and neosynephrine Taken to OR, monitors applied, Oxygen saturation 93% and positive Carbon Dioxide on Capnography

6. Pink oral airway inserted and patient preoxygenated with mask as well as nasal cannula inserted into bilateral nasal trumpets Given 50 mcg of Fentanyl Unsuccessful attempt to visualize airway Pt moving too much for procedure Given 10 mg of Ketamine Pt began to desaturate on oxygen saturation monitor Bradycardia observed on EKG leads

7. LMA inserted but no carbon dioxide seen on capnography and pt continued to desaturate Surgical airway then performed by ENT ETT 6.0 inserted but still difficult ventilation ETT suctioned and ventilation continued Given Atropine for Bradycardia as well as Epinephrine Found to be in asystole on EKG No pulse Code Blue called and CPR begun