A 6 year old girl develops respiratory distress post extubation following a neurosurgical procedure. She does not respond to nebulized adrenaline and intravenous dexamethasone. She deteriorates rapidly and a decision is made to secure her airway. It is difficult to support her breathing with bag-mask ventilation. Laryngoscopy is performed and it is impossible to visualise her vocal cords and blind attempts at intubation are unsuccessful. Outline your approach to this problem.
- Call for help (Intensive care/Anaesthesia/ENT colleagues)
– Examine reasons for difficult laryngoscopy –
a) was she a difficult intubation in the 1st instance b) Poor positioning of head
c) Faulty suction, wrong laryngoscope blade
d) Use of wrong sized ETT through a swollen cords
- Important to recognise that people die from failed intubation because of failure to oxygenate, not failure to intubate
- Ensure ongoing bag-mask ventilation
- Use of LMA as an airway or as a conduit for fiberoptic intubation.
-If LMA not successful, try reintubation with bougie + laryngeal pressure to improve visualisation -
- If despite all of these, still cannot ventilate, consider cricothyroidotomy / tracheostomy
Additional points that may score marks
a) Attempt at intubation to be made with gaseous induction, two anaesthetists and full range of difficult intubation options, if it is safe to move to OT, but most PICUs can do this.
b) Mentioning that cricothyroidotomy is difficult in child
c) As nature of neurosurgery not known, mention of worsening ICP because of hypercarbia adds to the emergent nature of the situation
This is a discussion of a "can't intubate, can't ventilate" algorithm.
Everybody should have one. ANZCA certainly suggests several. They dont specifically endorse any specific algortithm, but rather suggest that airway experts should have in their repertoir at least one.
For the answer to this question, I used the algorithm suggested by Heard et al.
Heard, A. M. B., R. J. Green, and P. Eakins. "The formulation and introduction of a ‘can't intubate, can't ventilate’algorithm into clinical practice." Anaesthesia64.6 (2009): 601-608.
Stacey, Jonathan, et al. "The ‘Can't Intubate Can't Oxygenate’scenario in Pediatric Anesthesia: a comparison of different devices for needle cricothyroidotomy." Pediatric Anesthesia 22.12 (2012): 1155-1158.