Initial Management

The posterior nosebleed was initially addressed using gauze soaked in oxymetazoline with viscous lidocaine placed into the left naris, with no significant bleeding coming from the right naris. At this time, the patient started to have a larger amount of oropharyngeal contamination with gurgling and increased coughing. Assuming failure of the initial management strategy, the oxymetazoline-soaked gauze was replaced by a nasal packing soaked in tranexamic acid, and a nose clamp was applied. The external venous oozing was controlled; however, it was found that the patient was becoming lethargic and had decreasing mental status and oxygen saturations. Otolaryngology (ENT) was emergently consulted and the patient was brought to a resuscitation bay because of worry concerning possible aspiration secondary to posterior epistaxis, requiring further airway stabilization. Assuming a difficult airway, both a video laryngoscope and cricothyroidotomy kit were prepared at bedside. ENT arrived and placed bilateral nasal packing with 10-cm nasal packing. The non-rebreather was increased to 15 L per minute without initial bag-valve mask assistance due to concern for worsening an already aspirated airway.

She was kept upright until immediately before paralytic administration. The patient was transitioned to a reverse Trendelenburg position to keep the head upright, and direct laryngoscopy was performed. There was a significant amount of blood collecting in the laryngopharynx with rundown from the nasopharynx obscuring the vocal cords. These contents were suctioned vigorously. A DuCanto suction device was placed along the base of the tongue towards the upper esophageal inlet and left in place to continuously suction the airway, preventing further aspiration of gastric and nasopharyngeal contents utilizing the suction assisted laryngoscopy and airway decontamination (SALAD) technique. The laryngoscope blade was introduced shortly afterwards. Three attempts at passing the endotracheal tube were made, due to significant hemorrhaging from the nasopharyngeal area, anterior location of the vocal cords, and an anatomically small laryngeal opening.

It Was a Difficult Airway

After the third attempt at intubation, the vocal cords were visualized and a size 6.5 endotracheal tube was passed, with eventual airway stabilization. Blood continued to accumulate in the laryngopharynx, but was eventually stopped with the combination of bilateral nasal packing and constant suctioning. A total of 400 mL of blood was suctioned throughout the procedure

The SALAD Approach to Airway Management

The presence of contaminants in the airway has been shown to decrease first-pass success at intubation, regardless of whether direct or video laryngoscopy is employed.^1-7 Patients with significant blood, emesis and secretions seen during laryngoscopy can be alleviated by continually suctioning the hypopharynx, reducing the chance of failure to intubate.^8,9 The SALAD maneuver was developed to overcome the challenges faced during intubation of a massively contaminated airway.¹⁰ This technique is not only valuable for preventing aspiration of contents from the gastrointestinal system during intubation, but also those from nasopharyngeal sources such as epistaxis. Therefore, the SALAD approach should be considered in any instance where an aspiration risk exists, whether it be esophageal, nasopharyngeal, or oropharyngeal.