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

C

·      IV access

·      IV fluid

·      Vasopressor

D

·      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.Plan:

Prepare for transfer

·      Airway equipment: portable video laryngoscope

·      Drugs: paleo anaesthetic (ket & sux)

·      Oxygen: full cylinder

·      Clear passage and open lift

Prepare 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