1. Sydney Clinical Skills and Simulation Centre Management of the Critically Obstructed Airway Session 2: Supraglottic Airway Rescue and Transition to Infraglottic Airway Rescue (Acknowledgements: adapted from talks by Dr Jamie Beit, Toowoomba), Helen Zois (Sydney) and Adam Rehak (Sydney)

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. DAS summary flowchart

5. Benumof JL, Dagg R, Benumof R (1997) Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 87: 979-82.

6. The Vortex model Desaturation With permission Chrimes N & Fritz P 2013

7. The Vortex model

11. Surgical airway (Infraglottic rescue) Supraglottic Rescue The Vortex model

12. Video

13. Best attempt face-mask ventilation  Optimal position (ear > sternum)  Head tilt chin lift jaw thrust  2 handed BMV  Second person ventilates  High fresh gas flows (O 2 flush)  Oro/Nasopharyngeal airway  Cricoid off

14. Best attempt endotracheal intubation  Best person in room  Best position (tragus >sternum)  Best blade (e.g., videolaryngoscope)  External laryngeal Manipulation (ELM)  Bougie or stylet (only1 blind attempt)  Consider muscle relaxant (if experienced)  Cricoid off

15. Best attempt LMA ventilation  Different type (e.g. Proseal™)  Different size  Insert under direct vision)  Insertion with jaw thrust  Pull tongue forward  Cricoid off  Consider muscle relaxant (if experienced)

16. There is no ideal number of attempts for face mask ventilation, endotracheal intubation or LMA ventilation. A best attempt: may involve >1 attempt is unlikely to be beneficial with >3 attempts How many attempts?

17. 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 smsc@nsccahs.health.nsw.gov.au. 2013smsc@nsccahs.health.nsw.gov.au NO TRANSITION ‘Transition’ protocol - CICO MOBILISE RESOURCES FOR CICO