can’t intubate can’t oxygenate (cico)

Sydney Clinical Skillsand Simulation Centre

Can’t Intubate Can’t Oxygenate (CICO)

Management of the Critically Obstructed AirwaySession 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)

CICO Plan

Part 1Supraglottic Airway Rescue

Part 2Transition to CICO

Part 3Infraglottic Airway Rescue

DAS summary flowchart

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

The Vortex model

Desaturation

With permission Chrimes N & Fritz P 2013

The Vortex model

The Vortex model

The Vortex model

The Vortex model

Surgical airway (Infraglottic rescue)

Supraglottic Rescue

The Vortex model

Video

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

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

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)

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

How many attempts?

Best attempt at:• Face-mask ventilation?• LMA ventilation? • Endotracheal intubation? AND

Oxygen saturations falling or persistently low?

Is this a CICO situation?

INFRAGLOTTIC RESCUE

YES

Continue Supraglottic

rescue

Consider waking patient

Review again in 1 min

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

SUPRA-GLOTTIC RESCUE

NO

TR

AN

SIT

ION

‘Transition’ protocol - CICO

MOBILISE RESOURCES

FOR CICO