You are intubating an hypoxic patient with rapid sequence induction.   

You are unable to visualise the cords during laryngoscopy. What is your plan to manage this problem

[Click here to toggle visibility of the answers]

College Answer

This question required a safe management plan that would cover the possible contingencies. The candidate should have mentioned that proper planning and assessment is the key but details of preparation were not specifically asked for.

Thus one approach is:

(a)  If one is able to ventilate the patient:
•   optimise laryngoscopy -extra pillow, McCoy blade, laryngeal manipulation etc.
•   consider alternatives to laryngoscopy- fiberoptic laryngoscopy
•  blind nasal, light wand
•  call for expert help
•   awaken patient

(b} If one is unable to ventilate the patient:
•   call for expert help
•     insert guedel airway and attempt ventilation with PEEP
•    insert LMA and attempt ventilation
•    if successful go to (a)
•   if unsuccessful attempt to establish a transtracheal airway
-     retrograde wire, cricothyrotomy, tracheostomy.

lt was assumed that suction. s .ECG, BP measurements were all preoptimised

Discussion

Again, this is a question regarding the difficult intubation algorithm.

  • call for expert help
  • Why cant you see the cords?
    • position the patient corectly
  • if you can ventilate, try one of the following:
    • get an assistant to manipulate the larynx
    • get a McCoy blade
    • get a videolaryngoscope
    • prepare a bronchoscope
    • consider waking the patient up, and using CPAP until help arrives
  • If you cannot ventilate:
    • Insert a nasopharyngeal airway and/or an oropharyngeal airway
    • Attempt two-handed mask technique with an assistant
    • If this is not working, convert to an LMA.
    • If LMA ventilation is sucessful, one can prepare for a repeat attempt at intubation.
    • If LMA ventilation is not successful, one needs to urgently proceed to needle cricothyroidotomy and jet oxygenation
      • If jet oxygenation can be accomplished, one has some time to set up for a Seldinger dilation and insertion of an ETT, or for a retrgrade intubation.
      • If jet ventilation cannot be accomplished, one must assess the difficulty of anterior neck anatomy.
        • if the anatomy is easy, one can proceed to a scalpel-bougie technique (where one makes an incision in the cricothyroid membrane and railroads the tube in over a hollow jet ventilation bougie)
        • if the anatomy is difficult, one must perform a scalpel-needle cricothyroidotomy (where the cricothyroid membrane is identified by palpation through an incision, so that the jet cannula can be inserted)
      • Either way, once the needle is in the airway it can be easily dilated and "up-sized" to a cricothyroidotomy.
      • A Griggs forceps tracheostomy (blind, without bronchoscope guidance) is also an option, and in some skilled hands it can be performed in 30 seconds (at least when the people who developed this technique are doing it).