Cant Intubate Cant Oxygenate CICO Management of the

Can’t Intubate Can’t Oxygenate (CICO) Management of the Critically Obstructed Airway Session 2: Supraglottic Airway Rescue and Transition to Infraglottic Airway Rescue Sydney Clinical Skills and Simulation Centre (Acknowledgements: adapted from talks by Dr Jamie Beit, Toowoomba), Helen Zois (Sydney) and Adam Rehak

CICO Plan Part 1 Supraglottic Airway Rescue Part 2 Transition to CICO Part 3 Infraglottic Airway Rescue

DAS summary flowchart

Benumof JL, Dagg R, Benumof R (1997) Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 87: 979 -82.

The Vortex model Desaturation With permission Chrimes N & Fritz P 2013

The Vortex model

The Vortex model

The Vortex model

The Vortex model

The Vortex model Supraglottic Rescue Surgical airway (Infraglottic rescue)

Video

Best attempt face-mask ventilation § § § § Optimal position (ear > sternum) Head tilt chin lift jaw thrust 2 handed BMV Second person ventilates High fresh gas flows (O 2 flush) Oro/Nasopharyngeal airway Cricoid off

Best attempt endotracheal intubation § § § § Best person in room Best position (tragus >sternum) Best blade (e. g. , videolaryngoscope) External laryngeal Manipulation (ELM) Bougie or stylet (only 1 blind attempt) Consider muscle relaxant (if experienced) Cricoid off

Best attempt LMA ventilation § § § § Different type (e. g. Proseal™) Different size Insert under direct vision) Insertion with jaw thrust Pull tongue forward Cricoid off Consider muscle relaxant (if experienced)

How many attempts? There is no ideal number of attempts for face mask ventilation, endotracheal intubation or LMA ventilation. A best attempt: • may involve >1 attempt • is unlikely to be beneficial with >3 attempts

TRANSITION ‘Transition’ protocol - CICO Is this a CICO situation? NO Best attempt at: • Face-mask ventilation? • LMA ventilation? • Endotracheal intubation? AND Oxygen saturations falling or persistently low? YES INFRAGLOTTIC RESCUE With permission A. Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) ‘Critically Obstructed Airway Workshop’. Contact smsc@nsccahs. health. nsw. gov. au. 2013 Continue Supraglottic rescue Consider waking patient Review again in 1 min MOBILISE RESOURCES FOR CICO