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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 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).

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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 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 2 Transition to CICO Part 3 Infraglottic Airway Rescue

  3. DAS summary flowchart

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

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

  6. The Vortex model

  7. The Vortex model

  8. The Vortex model

  9. The Vortex model

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

  11. Video

  12. 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 (O2 flush)  • Oro/Nasopharyngeal airway  • Cricoid off 

  13. 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 

  14. 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) 

  15. How many attempts? • 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

  16. ‘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

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