Tracheal intubation algorithm

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Plan A: Initial tracheal intubation plan

• Direct laryngoscopy

• Check:

• Neck flexion and head extension

• Laryngoscope technique and vector

• External laryngeal manipulation - by laryngoscopist

• Vocal cords open and immobile

• If poor view: Introducer (bougie) - seek clicks or hold-up and/or alternative laryngoscope

• Succeed? <br>Not more than 4 attempts. Maintaining 1) oxygenation with face mask and 2) anaesthesia

  Yes

  No - failed intubation

• Tracheal intubation

• Tracheal intubation verified?<br>

  Yes

  No

• How was tracheal intubation verified?

  Select visual capnograph oesophageal detector

  • visual
  • capnograph
  • oesophageal detector

• Proceed with surgery

• "If in doubt, take it out"

Plan B: Secondary tracheal intubation plan

• ILMA or LMA

• Succeed? <br>Not more than 2 insertions <br>Oxygenate and ventilate<br>

  Yes

  No - failed oxygenation

• Confirm: Ventilation

• Confirm: Oxygenation

• Confirm: Anaesthesia

• Confirm: CVS stability

• Confirm: Muscle relaxation

• Fibreoptic tracheal intubation through IMLA or LMA - 1 attempt
  If LMA consider long flexometallic, nasal RAE or microlaryngeal tube

• Fibreoptic tracheal intubation through IMLA or LMA verified?

  Yes

  No

• How was tracheal intubation verified?

  Select visual capnograph oesophageal detector

  • visual
  • capnograph
  • oesophageal detector

• Proceed with surgery

• Postpone surgery
  Awaken patient

Plan C: Maintenance of oxygenation, ventilation, postponement of surgery and awakening

• Revert to face mask
  Oxygenate and ventilate
  Reverse non-depolarising relaxant
  1 or 2 person mask technique

• Succeed?

  Yes

  No - failed ventilation and oxygenation

• Postpone surgery
  Awaken patient

Plan D: Rescue techniques for "can't intubate, can't ventilate" situation

• LMA

• Improved oxygenation?

  Yes

  No - increasing hypoxaemia

• Awaken patient

• Cannula cricothyroidotomy or surgical cricothyroidotomy?

  cannula cricothyroidotomy

  surgical cricothyroidotomy

• Cannula cricothyroidotomy
  http://www.aic.cuhk.edu.hk/web8/dilational_cricothyrotomy.htm

• 

• more information

• Equipment: Kink-resistant cannula, e.g. Patil (Cook) or Ravussin (VBM), high-pressure ventilation system, e.g. Manujet III (VBM)
  
  Technique:
  1. Insert cannula through cricothyroid membrane
  2. Maintain position of cannula - assistant's hand
  3. Confirm tracheal position by air aspiration - 20ml syringe
  4. Attach ventilation system to cannula
  5. Commence cautious ventilation
  6. Confirm ventilation of lungs and exhalation through upper airway
  7. If ventilation fails or surgical emphysema or any other complication develops - convert immediately to surgical cricothyroidotomy

• Cannula cricothyroidotomy successful?

  Yes

  No

• Surgical cricothyroidotomy

• 

• more information

• Equipment: Scalpel - short and rounded (no. 20 or Minitrach scalpel), small (e.g. 6 or 7 mm) cuffed tracheal or tracheostomy tube
  
  4-step technique:
  1. Identify cricothyroid membrane
  2. Stab incision through skin and membrane, enlarge incision with blunt dissection (e.g. scalpel handle, forceps or dilator)
  3. Caudal traction on cricoid cartilage with tracheal hook
  4. Insert tube and inflate cuff
  Ventilate with low-pressure source
  Verify tube position and pulmonary ventilation

• Surgical cricothyroidotomy

• 

• more information

• Equipment: Scalpel - short and rounded (no. 20 or Minitrach scalpel), small (e.g. 6 or 7 mm) cuffed tracheal or tracheostomy tube
  
  4-step technique:
  1. Identify cricothyroid membrane
  2. Stab incision through skin and membrane, enlarge incision with blunt dissection (e.g. scalpel handle, forceps or dilator)
  3. Caudal traction on cricoid cartilage with tracheal hook
  4. Insert tube and inflate cuff
  Ventilate with low-pressure source
  Verify tube position and pulmonary ventilation