Can't Ventilate & Can't Intubate!!!

Question 1

Can’t mask ventilate, what do you do next?

Answer 1

Oral airway / nasal airway, mask.

Question 2

Can’t mask ventilate with an oral airway by yourself, what do you do next?

Answer 2

Two handed mask & coworker squeezes the bag.

Question 3

Can’t two handed mask ventilate with an oral airway, what do you do next?

Answer 3

LMA

Question 4

Can’t ventilate with a LMA, what do you do next?

Answer 4

Push paralytic (if not already in), direct laryngoscopy & ETT intubation.

Question 5

Direct Laryngoscopy: Can’t intubate with ETT & stylet, what do you do next?

Answer 5

Try intubating with a bougie.

Question 6

Direct Laryngoscopy: Can’t intubate with a bougie, what do you do next?

Answer 6

Try intubating with a video laryngoscope.

Question 7

Video Laryngoscopy: Can’t intubate with ETT and stylet, what do you do next?

Answer 7

Try intubating with a bougie and the video laryngoscope.

Question 8

Video Laryngoscopy: Can’t intubate with a bougie, what do you do next?

Answer 8

Try intubating with a flexible intubation scope (fiberoptic).

Question 9

Can’t intubate with a flexible intubation scope (fiberoptic), what do you do next?

Answer 9

Needle cricothyrotomy & jet ventilation.

Question 10

What needle catheter do you want for needle cricothyrotomy?

Answer 10

Cook Emergency Transtracheal Airway Catheter

Question 11

If you don’t have access to a Cook Emergency Transtracheal Airway Catheter, and you need to perform an emergency needle cricothyrotomy, what should you use?

Answer 11

An IV catheter (as big as possible)

(14 gauge is about the same size as the Cook Emergency Transtracheal Catheter)

*This is not recommended practice. It can be dangerous because an IV catheter may be inadequate to achieve ventilation and is more likely to kink.

Question 12

How do you perform a needle cricothyrotomy?

Answer 12

Attach a needle catheter to a 10cc syringe with some fluid in it
Feel the cricothyroid membrane
Stand at the side of the patients head
Rest your hand with the needle on top of the patient’s chin
Insert the needle into the cricothyroid membrane pointing slightly down the trachea
Aspirate as you advance the needle until you get bubbles in the syringe
Thread the catheter and remove the needle
Attach the catheter to the jet ventilator
Ventilate with the jet ventilator

Question 13

If you do not have access to a jet ventilator and you need to perform a cricothyrotomy what do you do?

Answer 13

Perform a surgical cricothyrotomy. If you perform a needle cricothyrotomy, bagging the patient will be too difficult through the small catheter that you will be unable to ventilate the patient. You may be oxygenating slightly by providing oxygen through the catheter into their lungs, but you will not be able to create enough pressure in the lungs to expand them, and will therefore not be ventilating. Your O2 may stay adequate slightly longer, but your CO2 will continue to climb and they will die.

Question 14

Can’t ventilate with needle cricothyrotomy, what do you do next?

Answer 14

Surgical cricothyrotomy

Question 15

How do you perform a surgical cricothyrotomy?

Answer 15

Feel Cricothyroid Membrane
At a 90 degree angle (straight into the neck), cut a horizontal incision with a scalpel (left to right)
Insert & Hold your Finger in the Hole (can feel inside the trachea behind the cricoid cartilage)
Insert a Bougie through the hole, down into the trachea
Slide a size 6 ETT over the Bougie into the Trachea
Inflate the Cuff
Ventilate

Question 16

What if you can’t palpate the cricothyroid membrane well? How do you perform a surgical cricothyrotomy?

Answer 16

Start with a surgical cutdown. Make a vertical incision from the thyroid cartilage down several centimeters to the cricoid cartilage, dissect the tissue with your fingers and feel for the cricothyroid cartilage. Then make your horizontal incision in the cricothyroid cartilage and stick your finger in it. Bougie, tube, ventilate.

Question 17

How many attempts do you get at laryngoscopy before you should consider moving to an emergency surgical airway?

Answer 17

Max of 3 attempts is allowed by most difficult airway algorithms (around 5 minutes). You do not want to delay the surgical airway and cause hypoxic brain damage or death.