Beyond the algorithm...

1. Beyond the algorithm... John Moore Teaching the teachers Tracheostomy Safety Project 2011

3. When the expert arrives... • There will be one of 3 situations • First responder has resolved the situation Supportive intervention only • Stable patient oxygenating by face or stoma May need sedation or anaesthetic to facilitate re-intubation or re-fashioning of stoma Non-emergency situation • A loss of airway crisis......

4. Advanced algorithm

7. Failed definitive airway management • Get further help as appropriate • Continue to attempt to oxygenate/ventilate via stoma and upper airway/Face mask/LMA • Advanced upper airway management with FOB. LMA, Aintree, Advanced laryngoscopes • FOB into stoma without Aintree maybe more flexible • Cricothyroidotomy • New percutaneous or surgical tracheostomy

8. Continue to attempt to oxygenate/ventilate via stoma and upper airway Face mask LMA Further help ICU Anaesthetists ENT/Max-fax Arrest team

9. Continue to attempt to oxygenate/ventilate via stoma and upper airway Face mask LMA Further help ICU Anaesthetists ENT/Max-fax Arrest team

10. Cases...Beyond the algorithm

11. Post-op major max-fax 2 days On HDU, coughing+ Increasing oxygen requirements CO2 shows reduced trace... 45 mins later Patient becoming very agitated SaO2 89% on CPAP

12. Team arrive Patient now SaO2 80% Still breathing but awful respiratory pattern Patient critically hypoxia Airway likely difficult Management please

13. Algorithm • The right team • Equipment • When to give drugs and which ones • Alternative airway

14. Recovering swine flu patient ICU Percutaneous tracheostomy 4 days ago Weaning well since Now very tachypnoeic

15. No problem.......... use the algorithm Patient quickly deteriorates and arrests! You take trach out but can’t ventilate through airway or stoma

16. Could it be something else.. You bronchoscope...... Options...