Audit

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?
Not more than 4 attempts. Maintaining 1) oxygenation with face mask and 2) anaesthesia

Tracheal intubation

Tracheal intubation verified?

How was tracheal intubation verified?

Proceed with surgery

"If in doubt, take it out"

Plan B: Secondary tracheal intubation plan

ILMA or LMA

Succeed?
Not more than 2 insertions
Oxygenate and ventilate

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?

How was tracheal intubation verified?

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?

Postpone surgery
Awaken patient

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

LMA

Improved oxygenation?

Awaken patient

Cannula cricothyroidotomy or surgical cricothyroidotomy?

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

dilati8

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?

Surgical cricothyroidotomy

gesu_01_img0066

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

gesu_01_img0066

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

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.