Airway disaster on the ward

Situation:

· MET call on the ward

· Airway pathology (e.g. tumour, abscess)

· Morbidly obese

· Severe hypoxaemia

· Agitation

Q: what will you do?

Issues:

· Difficult airway

· Needs definitive procedure now

· Hostile environment

Approach:

1. Assess

2. Temporise

3. Decide

4. Plan

5. Do

1.Assess:

Questions

· Arrest or peri-arrest?

· Should I be team leader or airway person?

History

· From patient/nurse/doctor

· What’s the story? (HOPC)

· What’s the backstory? (PMHx etc)

Examination

· A: patent? Spont vent?

· B: chest movement bilat? Air entry? SpO2?

· C: perfused skin? HR and BP?

· D: AVPU?

2.Temporise:

A&B

· Sitting up

· Air viva + reservoir bag + 100% O2 + CPAP

· Two operators

· IV access

· IV fluid

· Vasopressor

· Ketamine 10mg q2min PRN

3.Decide:

Options

· ‘Stay and play’ = manage on the ward

· ‘Scoop and run’ = manage in theatre

(note different to the blue book description)

Considerations

· Urgency (i.e. arrest or not)

· Logistics (i.e. distance to theatre)

· Equipment (e.g. video scope, ventilator)

· Monitoring (e.g. capno)

· Personnel (e.g. anaes nurse, ENT surgeon)

ASSUME SCOOP AND RUN

4.Prepare

For transfer

· Airway equipment: portable video laryngoscope

· Drugs: paleo anaesthetic (ket & sux)

· Oxygen: full cylinder

· Clear passage and open lift

For theatre

· Personnel: anaes nurse + 2nd anaesthetist + ENT surgeon

· Equipment: oxford ramp, HFNP, hyperangulated video scope, fibreoptic bronchoscope w fastrach

· Monitoring: anaes machine

5.Do

Goals

· Definitive airway

· Prevent soiling

· Prevent cardiovascular collapse

Induction plan

· mRSI accepting some risk of aspiration

Airway plan

· A: hyperangulated videoscope

· B: hyperangulated videoscope + fibroptic bronchoscope w fastrach
(two operator)

· C: bag-mask + guedel + 2 hands

· D: LMA

· Z: hole in the neck