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Failed Intubation
Alan Hope, 14 May 2023
You have failed to intubate the trachea of an anaesthetised patient. You have repositioned the head to optimise intubating position and have had a second attempt at laryngoscopy using cricoid pressure and a bougie but have been unable to access the trachea. You have inserted a guedel airway. You are unable to oxygenate the patient with bag and mask ventilation.
flowchart TD
A{INSERT AN LMA
Can you
oxygenate?} style A fill:#efe C{CALL FOR HELP
Try bag/mask
ventilation again
Can you
oxygenate?} D{"FON ACCESS
Can you palpate
the cricothyroid (CT)
membrane?"} E[LOCATE CT MEMBRANE
10cm vertical incision
Blunt dissection trachea
using fingers] F[INTUBATE VIA CT MEMBRANE
Transverse incision
Twist scalpel
Insert bougie
Railroad 6mmCOETT] G{OXYGENATE
Life-saving
surgery?} H([Waken the patient up.
Reverse muscle relaxant.
Postpone surgery.]) style H fill:#ffc I["Intubate through LMA
Consider awake intubation.
Consider tracheostomy (asleep / awake)."] J([Surgery]) style J fill:#ffc K{Easy to ventilate
and surgery feasible
with LMA or FMask?} L{Secure airway?} A -->|Yes| G A -->|No| C C -->|Yes| G C -->|No| D D -->|Yes| F D -->|No| E E --> F G --->|No| H G -->|Yes| L L -->|No| K L -->|Yes| J F --> G I --> J K -->|Yes| J K --> |No| I subgraph DANGER_OF_HYPOXIA A C D E F end style DANGER_OF_HYPOXIA fill:#fee,stroke:#fdd,stroke-width:1px,color:maroon; subgraph PATIENT_SAFE G H I J K L end style PATIENT_SAFE fill:#efe,stroke:#ded,stroke-width:1px,color:green;
Can you
oxygenate?} style A fill:#efe C{CALL FOR HELP
Try bag/mask
ventilation again
Can you
oxygenate?} D{"FON ACCESS
Can you palpate
the cricothyroid (CT)
membrane?"} E[LOCATE CT MEMBRANE
10cm vertical incision
Blunt dissection trachea
using fingers] F[INTUBATE VIA CT MEMBRANE
Transverse incision
Twist scalpel
Insert bougie
Railroad 6mmCOETT] G{OXYGENATE
Life-saving
surgery?} H([Waken the patient up.
Reverse muscle relaxant.
Postpone surgery.]) style H fill:#ffc I["Intubate through LMA
Consider awake intubation.
Consider tracheostomy (asleep / awake)."] J([Surgery]) style J fill:#ffc K{Easy to ventilate
and surgery feasible
with LMA or FMask?} L{Secure airway?} A -->|Yes| G A -->|No| C C -->|Yes| G C -->|No| D D -->|Yes| F D -->|No| E E --> F G --->|No| H G -->|Yes| L L -->|No| K L -->|Yes| J F --> G I --> J K -->|Yes| J K --> |No| I subgraph DANGER_OF_HYPOXIA A C D E F end style DANGER_OF_HYPOXIA fill:#fee,stroke:#fdd,stroke-width:1px,color:maroon; subgraph PATIENT_SAFE G H I J K L end style PATIENT_SAFE fill:#efe,stroke:#ded,stroke-width:1px,color:green;