A question you always want to know about tracheal intubation: What to do if I can’t intubate a patient?

Outcomes of the difficult intubation in malpractice claims

My own experience I couldn’t intubate a patient with respiratory arrest on my first duty in ICU. Retrograde intubation was performed successfully. In a patient with severe airway obstruction emergency tracheostomy was made Difficult intubation before elective surgical procedure. Blind nasal intubation failed. The patient was intubated by a chief of the department A cuff of the tube was ruptured in the middle of an operation. Re-intubation after 3rd attempt

Is it real in our every day life? A call was received by the medical director of the clinic: a worker from a major construction company fell down from the height. They are in 10 min from the clinic, accompanied by a nurse from the company. The nurse is very nervous: the man can’t b breath and she’s trying to ventilate him by mask. A patient admitted to our holding room: He’s severely obtunded. T-40C, RR-36’, HR-140’, SO2-72%, improved to 78% on 12 l/min of oxygen. CXR- bilateral pneumonia.

Continue A doctor from the clinic escorts an unconscious patient to the hospital. The patient’s condition deteriorates, SO2 drops despite supplementary oxygen inhalation. In the medical unit of SVO2, the staff tried to manage an unconscious patient in apparent respiratory distress who admitted about 5 minutes ago Air evacuations: 5 intubations were performed.

Emergency intubation vs elective one

Reasons for intubation in emergency situation Hypoxia Hypoventilation ( hypercapnia) Unconscious patient who’s unable to protect his/her airway Too labored breathing put patient's condition in danger Unstable patient A patient who can’t be managed without intubation

Make a decision on the base of the whole picture! 18 y.o. girl with APL admitted to the ICU. She is very weak and disoriented. VS: RR- 28’, HR-120’, BP-120/80, SaO2-40%. PaO2- 32, PaCO Breathing is unlabored. 46 y. o. man admitted to the ICU due to long-term respiratory failure. VS: RR-24, BP-140/90, SaO2 -40, PaO2-44, PaCO2-55

Continue 10 years old boy with blunt head trauma and mandibular fracture after car accident. He was hospitalized to an ICU, 36 hours before arrival our evacuation team. GCS-7. VS: RR-22’, HR=120’, BP-110/80, SaO2- 92% on room air. Breathing spontaneously. There is blood in the oral cavity. Tympanic membrane on the left with hemorrhage.

Physiology (a little) Hypoxia: hyperventilation will be pronounced when the PaO2 falls to 40.2 mm Hg, coma occurs when PaO2 is below 32.7 mm Hg (BMJ: ABC of oxygen transport ) Hypercapnia: A healthy person will bear PaCO2 75 mm Hg without any damage In case of apnoea when airway are open and oxygen is the ambient mask, the patient can theoretically survive 100 minutes (JF Nunn)

Principal stores of body oxygen Fully preoxygenated patient can survive up to 8 min without becoming hypoxic

Types of translaryngeal intubation

Multiple choice questions: Smart thoughts before the start Why I didn’t go to the business school instead of medical university? Should I ask for help? They don’t pay me enough The clinic is unprepared for this, nurses poorly trained, medical director… and etc What should I do before? Do I have a plan?

Answers Measures before: a) how to improve oxygenation, ventilation and protect airway? b) Do I monitor the patient properly? Heeeelp (will not work): who to ask, when and what to ask What about a plan?

If you failed…?

Every boxer had a plan until he missed first strong punch Mike Tyson (philosopher) Better don’t say that I’m wrong

If you failed mask ventilation is possible continue ventilation protect airway make another attempt don’t forget about external maneuvers mask ventilation isn’t possible Try jaw thrust oral or nasal airway clean secretion

Continue Intubation failed, but mask ventilation is possible-consider Continue mask ventilation until help is available Retrograde intubation Transtracheal ventilation with oral airway Remember Tyson? Transtracheal ventilation Combi tube Open cricotomy

Practice will help