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Sydney Clinical Skills and Simulation Centre Management of the Critically Obstructed Airway Session 4: Infraglottic Airway Rescue.

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Presentation on theme: "Sydney Clinical Skills and Simulation Centre Management of the Critically Obstructed Airway Session 4: Infraglottic Airway Rescue."— Presentation transcript:

1 Sydney Clinical Skills and Simulation Centre Management of the Critically Obstructed Airway Session 4: Infraglottic Airway Rescue

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

3 Session aims CICO infraglottic rescue: 1.Algorithm (A Heard) 2.Techniques 3.Kit 4.Team-based algorithm

4 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 Cant Intubate, Cant Ventilate Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pages 601– Dr A.M.B Heard. The Wet Lab-Emergency Airway Management Techniques for the Cant Intubate, Cant Oxygenate Scenario. March, 2011.

5 CICO algorithm (Heard) A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a Cant Intubate, Cant Ventilate Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608. Cannula Cricothyroidotomy or Cannula Tracheotomy Palpable Neck Airway Anatomy? Scalpel Finger Cannula Scalpel Bougie Melker 5.0 Cuffed Seldinger Technique Railroad size 6.0 ET Tube Melker 5.0 Cuffed Seldinger Technique Consider: Awaken/Other upper airway techniques FAILURE Oxygenate and stabilise SUCCESSFAILURE NO YES Oxygenate and stabilise FAILURE CICO

6 CICO techniques 1.Cannula Cricothyroidotomy 2.Jet oxygenation 3.Scalpel-bougie 4.Scalpel-finger-cannula 5.Melker size 5 cuffed Seldinger conversion to a definitive airway

7 Video – Cannula Cricothyroidotomy

8 Cannula cricothyroidotomy Equipment

9 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

10 The Manujet TM Set at 1.0 bar (i.e., Infant setting, in the Yellow Zone) delivers inspiratory flow of approx 250 mls/second Rapid - O 2 oxygen cricothyroidotomy insufflation device (nee Leroy) Connected to piped O 2 at 15L/min, delivers inspiratory flow of approx 250 mls/second Providing oxygen

11 Jet oxygenation in a 70kg male Initial breath 4 seconds duration=approx 1000mL If there is no response or improvement in SpO 2 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. Prevent/improve airway and alveolar collapse

12 Jet oxygenation in a 70kg male 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) Prevent/improve airway and alveolar collapse

13 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.

14 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 - O 2 (Leroy) / ENK (Or disconnected Manujet) even in complete upper airway obstruction.

15 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.

16 CICO algorithm (Heard) A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a Cant Intubate, Cant Ventilate Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608. Cannula Cricothyroidotomy or Cannula Tracheotomy Palpable Neck Airway Anatomy? Scalpel Finger Cannula Scalpel Bougie Melker 5.0 Cuffed Seldinger Technique Railroad size 6.0 ET Tube Melker 5.0 Cuffed Seldinger Technique Consider: Awaken/Other upper airway techniques FAILURE Oxygenate and stabilise SUCCESSFAILURE NO YES Oxygenate and stabilise FAILURE CICO

17 Video - Scalpel-Bougie

18 Scalpel-Bougie Equipment

19 CICO algorithm (Heard) A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a Cant Intubate, Cant Ventilate Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608. Cannula Cricothyroidotomy or Cannula Tracheotomy Palpable Neck Airway Anatomy? Scalpel Finger Cannula Scalpel Bougie Melker 5.0 Cuffed Seldinger Technique Railroad size 6.0 ET Tube Melker 5.0 Cuffed Seldinger Technique Consider: Awaken/Other upper airway techniques FAILURE Oxygenate and stabilise SUCCESSFAILURE NO YES Oxygenate and stabilise FAILURE CICO

20 Video – Scalpel Finger Cannula

21 Melker TM conversion Equipment

22 CICO infraglottic rescue Key points for success 1.CICO is recognised 2.CICO is declared 3.A plan is activated 4.Equipment is immediately available 5.People know their roles

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

24 Best attempt at supraglottic rescue? Oxygen saturations persistently low? Is this a CICO situation? DECLARE CICO CANT INTUBATE & CANT OXYGENATE (CICO) EMERGENCY PROTOCOL Resources 1. Cannula-cricothyroidotomy kit Jet oxygenation tubing Melker kit Self-inflating bag 2. Scalpel – bougie kit 3. Scalpel – finger – cannula kit 4. Arrest trolley NO Continue supraglottic rescue Consider waking patient Review again in 1 min With permission A. Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) Critically Obstructed Airway Workshop. Contact: SUPRAGLOTTIC RESCUE – MOBILISE RESOURCES FOR CICO INFRAGLOTTIC RESCUE Team roles ALGORITHM 1.Teamleader 2.Proceduralist – infraglottic rescue 3.Proceduralist – supraglotic rescue 4.Assistant – supraglotic rescue 5.Assistant – infraglottic rescue 6.Assistant – equipment set up 7.Scribe Algorithm Mobilise resources for CICO YES Face mask ventilation LMA ventilation Endotracheal intubation


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