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Can’t Intubate Can’t Oxygenate (CICO)

Can’t Intubate Can’t Oxygenate (CICO). Management of the Critically Obstructed Airway Session 4: Infraglottic Airway Rescue. CICO Plan. Part 1 Supraglottic Airway Rescue. Part 2 Transition to CICO. Part 3 Infraglottic Airway Rescue. Session aims. CICO infraglottic rescue:

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Can’t Intubate Can’t Oxygenate (CICO)

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  1. Can’t Intubate Can’t Oxygenate (CICO) Management of the Critically Obstructed Airway Session 4: Infraglottic Airway Rescue

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

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

  4. Acknowledgements • Dr Andy Heard - Original content • Expert Working Group, RHCE Critically Obstructed Airway Course References • Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pages 601–608. • Dr A.M.B Heard. The Wet Lab-Emergency Airway Management Techniques for the ‘Can’t Intubate, Can’t Oxygenate’ Scenario. March, 2011.

  5. CICO algorithm (Heard) CICO CannulaCricothyroidotomy or CannulaTracheotomy FAILURE SUCCESS Palpable Neck Airway Anatomy? NO YES Scalpel Finger Cannula Scalpel Bougie FAILURE Oxygenate and stabilise Oxygenate and stabilise Oxygenate and stabilise Melker 5.0 Cuffed Seldinger Technique Railroad size 6.0ET Tube Consider:Awaken/Other upper airway techniques Melker 5.0 Cuffed Seldinger Technique FAILURE A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.

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

  7. Video – CannulaCricothyroidotomy

  8. Cannulacricothyroidotomy Equipment

  9. Jet oxygenation You are trying to achieve 2 things with jet oxygenation in the CICO scenario: • Provide oxygen • Prevent/improve airway and alveolar collapse

  10. Jet oxygenation Providing oxygen The ManujetTM Set at 1.0 bar (i.e., Infant setting, in the Yellow Zone) delivers inspiratory flow of approx250 mls/second Rapid - O2oxygen cricothyroidotomy insufflation device (nee Leroy) Connected to piped O2 at 15L/min, delivers inspiratory flow of approx 250 mls/second

  11. Jet oxygenation in a 70kg male Prevent/improve airway and alveolar collapse Initial breath 4 seconds duration=approx 1000mL • If there is no response or improvement in SpO2after 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.

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

  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 - O2 (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) CICO CannulaCricothyroidotomy or CannulaTracheotomy FAILURE SUCCESS Palpable Neck Airway Anatomy? NO YES FAILURE Scalpel Finger Cannula Scalpel Bougie Oxygenate and stabilise Oxygenate and stabilise Oxygenate and stabilise Melker 5.0 Cuffed Seldinger Technique Railroad size 6.0ET Tube Consider:Awaken/Other upper airway techniques Melker 5.0 Cuffed Seldinger Technique FAILURE A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.

  17. Video - Scalpel-Bougie

  18. Scalpel-Bougie Equipment

  19. CICO algorithm (Heard) CICO CannulaCricothyroidotomy or CannulaTracheotomy FAILURE SUCCESS Palpable Neck Airway Anatomy? NO YES FAILURE Scalpel Finger Cannula Scalpel Bougie Oxygenate and stabilise Oxygenate and stabilise Oxygenate and stabilise Melker 5.0 Cuffed Seldinger Technique Railroad size 6.0ET Tube Consider:Awaken/Other upper airway techniques Melker 5.0 Cuffed Seldinger Technique FAILURE A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.

  20. Video – Scalpel Finger Cannula

  21. MelkerTM conversion Equipment

  22. CICO infraglottic rescue Key points for success • CICO is recognised • CICO is declared • A plan is activated • Equipment is immediately available • People know their roles

  23. ‘Transition’ protocol - CICO SUPRA-GLOTTIC RESCUE Continue Supraglottic rescue Consider waking patient Review again in 1 min TRANSITION Is this a CICO situation? NO • Best attempt at: • Face-mask ventilation? • LMA ventilation? • Endotracheal intubation? AND • Oxygen saturations falling or persistently low? MOBILISE RESOURCES FOR CICO YES INFRAGLOTTIC RESCUE 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. 2013

  24. CAN’T INTUBATE & CAN’T OXYGENATE (CICO) EMERGENCY PROTOCOL • 1. Cannula-cricothyroidotomy kit • Jet oxygenation tubing • Melker™ kit • Self-inflating bag • 2. Scalpel – bougie kit • 3. Scalpel – finger – cannula kit • 4. Arrest trolley Team roles Resources Algorithm SUPRAGLOTTIC RESCUE – MOBILISE RESOURCES FOR CICO Best attempt atsupraglottic rescue? Oxygen saturations persistently low? Is this a CICO situation? Face mask ventilation LMAventilation Endotracheal intubation Continue supraglottic rescue Consider waking patient Review againin 1 min NO Mobilise resources for CICO YES DECLARE CICO INFRAGLOTTIC RESCUE ALGORITHM • Teamleader • Proceduralist – infraglottic rescue • Proceduralist – supraglotic rescue • Assistant – supragloticrescue • Assistant – infraglottic rescue • Assistant – equipment set up • Scribe 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. 2013 .

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