can’t intubate can’t oxygenate (cico)
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Sydney Clinical Skillsand Simulation Centre
Can’t Intubate Can’t Oxygenate (CICO)
Management of the Critically Obstructed AirwaySession 4: Infraglottic Airway Rescue
CICO Plan
Part 1Supraglottic Airway Rescue
Part 2Transition to CICO
Part 3Infraglottic Airway Rescue
Session aimsCICO infraglottic
rescue:
1. Algorithm (A Heard)
2. Techniques
3. Kit
4. Team-based algorithm
Acknowledgements
Dr Andy Heard - Original content Expert Working Group, RHCE Critically Obstructed Airway
Course
References1. Heard, R. J. Green and P. Eakins. The Formulation and
Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pages 601–608.
2. Dr A.M.B Heard. The Wet Lab-Emergency Airway Management Techniques for the ‘Can’t Intubate, Can’t Oxygenate’ Scenario. March, 2011.
CICO algorithm (Heard)
A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.
Cannula Cricothyroidotomy or Cannula Tracheotomy
Palpable Neck Airway Anatomy?
Scalpel Finger Cannula
Scalpel Bougie
Melker 5.0 Cuffed Seldinger Technique
Railroad size 6.0ET Tube
Melker 5.0 Cuffed Seldinger Technique
Consider:Awaken/Other upper
airway techniques
FAILURE
Oxygenate and stabiliseOxygenate and stabilise
SUCCESSFAILURE
NO YES
Oxygenate and stabilise
FAILURE
CICO
CICO techniques
1. Cannula Cricothyroidotomy
2. Jet oxygenation
3. Scalpel-bougie
4. Scalpel-finger-cannula
5. Melker size 5 cuffed Seldinger conversion to a definitive airway
Video – Cannula Cricothyroidotomy
Cannula cricothyroidotomyEquipment
You are trying to achieve 2 things with jet oxygenation in the CICO scenario:
1. Provide oxygen
2. Prevent/improve airway and alveolar collapse
Jet oxygenation
Jet oxygenation
The ManujetTM
Set at 1.0 bar (i.e., Infant setting, in the Yellow Zone) delivers inspiratory flow of approx 250 mls/second
Rapid - O2 oxygen cricothyroidotomy insufflation device (nee Leroy)Connected to piped O2 at 15L/min, delivers inspiratory flow of approx 250 mls/second
Providing oxygen
Jet oxygenation in a 70kg male
Initial breath4 seconds duration=approx 1000mL
If there is no response or improvement in SpO2 after 30 seconds, a second jet of 2.0 seconds should be administered.
Whilst applying the first jet, signs of flow must be sought by checking the chest for movement, and listening for flow.
Prevent/improve airway and alveolar collapse
Jet oxygenation in a 70kg male
Subsequent breaths
Do not jet again until the SpO2 have dropped by 5% from the maximum achieved with the initial jet.
Subsequent jets should be of 2 seconds duration (Approx 500 mls)
Prevent/improve airway and alveolar collapse
Jet oxygenationIF jetting with the manujet, and there are no signs of expiratory flow
THEN disconnect the manujet to allow some expiration through the cannula (taking care to not inadvertently remove the cannula). This is to ensure hyperinflation causing reduced venous return does not occur.
The Leroy and ENK allow expiration through the cannula and do not require disconnection.
Jet oxygenationIF there is no saturation reading for whatever reason
THEN it is safe to insufflate 500 mls every 30 seconds if using a 14g cannnula and Rapid - O2 (Leroy) / ENK (Or disconnected Manujet) even in complete upper airway obstruction.
Jet oxygenation
After connecting the cannula to the jet oxygenation device, never let go of the cannula.
Only jet oxygenate whilst watching the chest rise and fall
The rate-limiting step for the frequency of safe jet oxygenation is the patency of the expiratory pathway.
CICO algorithm (Heard)
A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.
Cannula Cricothyroidotomy or Cannula Tracheotomy
Palpable Neck Airway Anatomy?
Scalpel Finger Cannula
Scalpel Bougie
Melker 5.0 Cuffed Seldinger Technique
Railroad size 6.0ET Tube
Melker 5.0 Cuffed Seldinger Technique
Consider:Awaken/Other upper
airway techniques
FAILURE
Oxygenate and stabiliseOxygenate and stabilise
SUCCESSFAILURE
NO YES
Oxygenate and stabilise
FAILURE
CICO
Video - Scalpel-Bougie
Scalpel-BougieEquipment
CICO algorithm (Heard)
A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.
Cannula Cricothyroidotomy or Cannula Tracheotomy
Palpable Neck Airway Anatomy?
Scalpel Finger Cannula
Scalpel Bougie
Melker 5.0 Cuffed Seldinger Technique
Railroad size 6.0ET Tube
Melker 5.0 Cuffed Seldinger Technique
Consider:Awaken/Other upper
airway techniques
FAILURE
Oxygenate and stabiliseOxygenate and stabilise
SUCCESSFAILURE
NO YES
Oxygenate and stabilise
FAILURE
CICO
MelkerTM conversionEquipment
CICO infraglottic rescueKey points for success
1. CICO is recognised
2. CICO is declared
3. A plan is activated
4. Equipment is immediately available
5. People know their roles
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
Best attempt at supraglottic rescue?
Oxygen saturations persistently low?
Is this
a CICO
situation?
DECLARE CICO
CAN’T INTUBATE & CAN’T OXYGENATE (CICO) EMERGENCY PROTOCOL
Resources
1. Cannula-cricothyroidotomy kit• Jet oxygenation tubing• Melker™ kit• Self-inflating bag
2. Scalpel – bougie kit3. Scalpel – finger – cannula kit4. Arrest trolley
NO
Continue supraglottic rescueConsider 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 .
SUPRAGLOTTIC RESCUE – MOBILISE RESOURCES FOR CICO
INFRAGLOTTIC RESCUE
Team roles
ALGORITHM
1. Teamleader2. Proceduralist – infraglottic rescue3. Proceduralist – supraglotic rescue4. Assistant – supraglotic rescue5. Assistant – infraglottic rescue6. Assistant – equipment set up7. Scribe
Algorithm
Mobilise resources for CICOYES
Face mask ventilationLMA ventilationEndotracheal intubation
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