Transcript Session 4
Management of the Critically Obstructed Airway Session 4: Infraglottic Airway Rescue Sydney Clinical Skills and Simulation Centre CICO Plan Part 1 Supraglottic Airway Rescue Part 2 Transition to CICO Part 3 Infraglottic Airway Rescue Session aims CICO infraglottic rescue: 1. 2. 3. 4. Algorithm (A Heard) Techniques Kit Team-based algorithm Acknowledgements Dr Andy Heard - Original content Expert Working Group, RHCE Critically Obstructed Airway Course References 1. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pages 601– 608. 2. Dr A.M.B Heard. The Wet Lab-Emergency Airway Management Techniques for the ‘Can’t Intubate, Can’t Oxygenate’ Scenario. March, 2011. CICO algorithm (Heard) CICO Cannula Cricothyroidotomy or Cannula Tracheotomy FAILURE SUCCESS Palpable Neck Airway Anatomy? NO Scalpel Finger Cannula YES FAILURE Oxygenate and stabilise Melker 5.0 Cuffed Seldinger Technique Scalpel Bougie Oxygenate and stabilise Railroad size 6.0 ET Tube Oxygenate and stabilise Consider: Awaken/Other upper airway techniques FAILURE Melker 5.0 Cuffed Seldinger Technique A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608. CICO techniques 1. 2. 3. 4. 5. Cannula Cricothyroidotomy Jet oxygenation Scalpel-bougie Scalpel-finger-cannula Melker size 5 cuffed Seldinger conversion to a definitive airway Video – Cannula Cricothyroidotomy Cannula cricothyroidotomy Equipment Jet oxygenation You are trying to achieve 2 things with jet oxygenation in the CICO scenario: 1. Provide oxygen 2. Prevent/improve airway and alveolar collapse Jet oxygenation Providing oxygen The ManujetTM Set at 1.0 bar (i.e., Infant setting, in the Yellow Zone) delivers inspiratory flow of approx 250 mls/second Rapid - O2 oxygen cricothyroidotomy insufflation device (nee Leroy) Connected to piped O2 at 15L/min, delivers inspiratory flow of approx 250 mls/second Jet oxygenation in a 70kg male Prevent/improve airway and alveolar collapse Initial breath 4 seconds duration=approx 1000mL If there is no response or improvement in SpO2 after 30 seconds, a second jet of 2.0 seconds should be administered. Whilst applying the first jet, signs of flow must be sought by checking the chest for movement, and listening for flow. Jet oxygenation in a 70kg male Prevent/improve airway and alveolar collapse Subsequent breaths Do not jet again until the SpO2 have dropped by 5% from the maximum achieved with the initial jet. Subsequent jets should be of 2 seconds duration (Approx 500 mls) Jet oxygenation IF jetting with the manujet, and there are no signs of expiratory flow THEN disconnect the manujet to allow some expiration through the cannula (taking care to not inadvertently remove the cannula). This is to ensure hyperinflation causing reduced venous return does not occur. The Leroy and ENK allow expiration through the cannula and do not require disconnection. Jet oxygenation IF there is no saturation reading for whatever reason THEN it is safe to insufflate 500 mls every 30 seconds if using a 14g cannnula and Rapid - O2 (Leroy) / ENK (Or disconnected Manujet) even in complete upper airway obstruction. Jet oxygenation After connecting the cannula to the jet oxygenation device, never let go of the cannula. Only jet oxygenate whilst watching the chest rise and fall The rate-limiting step for the frequency of safe jet oxygenation is the patency of the expiratory pathway. CICO algorithm (Heard) CICO Cannula Cricothyroidotomy or Cannula Tracheotomy FAILURE SUCCESS Palpable Neck Airway Anatomy? NO Scalpel Finger Cannula YES FAILURE Oxygenate and stabilise Melker 5.0 Cuffed Seldinger Technique Scalpel Bougie Oxygenate and stabilise Railroad size 6.0 ET Tube Oxygenate and stabilise Consider: Awaken/Other upper airway techniques FAILURE Melker 5.0 Cuffed Seldinger Technique A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608. Video - Scalpel-Bougie Scalpel-Bougie Equipment CICO algorithm (Heard) CICO Cannula Cricothyroidotomy or Cannula Tracheotomy FAILURE SUCCESS Palpable Neck Airway Anatomy? NO Scalpel Finger Cannula YES FAILURE Oxygenate and stabilise Melker 5.0 Cuffed Seldinger Technique Scalpel Bougie Oxygenate and stabilise Railroad size 6.0 ET Tube Oxygenate and stabilise Consider: Awaken/Other upper airway techniques FAILURE Melker 5.0 Cuffed Seldinger Technique A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608. Video – Scalpel Finger Cannula MelkerTM conversion Equipment CICO infraglottic rescue Key points for success 1. 2. 3. 4. 5. CICO is recognised CICO is declared A plan is activated Equipment is immediately available People know their roles 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 [email protected]. 2013 Continue Supraglottic rescue Consider waking patient Review again in 1 min MOBILISE RESOURCES FOR CICO CAN’T INTUBATE & CAN’T OXYGENATE (CICO) EMERGENCY PROTOCOL SUPRAGLOTTIC RESCUE – MOBILISE RESOURCES FOR CICO Is this Best attempt at supraglottic rescue? a CICO situation? Oxygen saturations persistently low? Face mask ventilation LMA ventilation Endotracheal intubation YES NO Continue supraglottic rescue Consider waking patient Review again in 1 min Mobilise resources for CICO DECLARE CICO INFRAGLOTTIC RESCUE Algorithm ALGORITHM Resources Team roles With permission A. Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) ‘Critically Obstructed Airway Workshop’. Contact: [email protected]. 2013 .