Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Society. intubation guidelines working group. British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371

DAS DIFFICULT INTUBATION GUIDELINES OVERVIEW: Western General Hospital

Plan

B:

Mai

ntai

ning

oxy

gena

tion:

SA

D in

serti

on

STO

P AN

D TH

INK

Opt

ions

(con

side

r ris

ks a

nd b

enefi

ts):

1. W

ake

the

patie

nt u

p2.

Intu

bate

trac

hea

via

the

SAD

3. P

roce

ed w

ithou

t int

ubat

ing

the

trach

ea4.

Tra

cheo

stom

y or

cric

othy

roid

otom

y

Succ

eed

Supr

aglo

ttic

Airw

ay

Devi

ce

Plan

C:

Face

mas

k ve

ntila

tion

Wak

e th

e pa

tient

up

Succ

eed

Fina

l atte

mpt

at f

ace

mas

k ve

ntila

tion

Plan

D:

Emer

genc

y fro

nt o

f nec

k ac

cess

Cric

othy

roid

otom

y

Plan

A:

Face

mas

k ve

ntila

tion

and

trach

eal i

ntub

atio

nTr

ache

al in

tuba

tion

Succ

eed

Lary

ngos

copy

Faile

d in

tuba

tion

Faile

d SA

D ve

ntila

tion

CICO

This

flow

char

t for

ms

part

of th

e D

AS G

uide

lines

for u

nant

icip

ated

diffi

cult

intu

batio

n in

adu

lts 2

015

and

shou

ld b

e us

ed in

con

junc

tion

with

the

text

.

DAS

Diffi

cult

intu

batio

n gu

idel

ines

– o

verv

iew

2015

Com

mun

icat

e th

e na

ture

of t

he e

mer

genc

y to

the

team

, cal

l for

sen

ior h

elp,

del

egat

e ta

sks

1

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Society. intubation guidelines working group. British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371

UNANTICIPATED DIFFICULT INTUBATION (DAS): Western General Hospital

Com

mun

icat

e th

e na

ture

of t

he e

mer

genc

y to

the

team

, cal

l for

sen

ior h

elp,

del

egat

e ta

sks

Man

agem

ent o

f una

ntic

ipat

ed d

ifficu

lt tr

ache

al in

tuba

tion

in a

dults

Suc

ceed

Suc

ceed

Suc

ceed

Dec

lare

faile

d in

tuba

tion

Dec

lare

faile

d S

AD

ven

tilat

ion

Dec

lare

CIC

O

Dec

lare

CIC

O

Opt

imis

e he

ad a

nd n

eck

posi

tion

Pre

oxyg

enat

eA

dequ

ate

neur

omus

cula

r blo

ckad

eD

irect

/ Vi

deo

Lary

ngos

copy

(max

imum

3+1

atte

mpt

s)E

xter

nal l

aryn

geal

man

ipul

atio

nB

ougi

eR

emov

e cr

icoi

d pr

essu

reM

aint

ain

oxyg

enat

ion

and

anae

sthe

sia

Plan

A: F

acem

ask

vent

ilatio

n an

d tra

chea

l int

ubat

ion

2nd

gene

ratio

n de

vice

reco

mm

ende

dC

hang

e de

vice

or s

ize

(max

imum

3 a

ttem

pts)

Oxy

gena

te a

nd v

entil

ate

Plan

B: M

aint

aini

ng o

xyge

natio

n: S

AD

inse

rtion

If fa

cem

ask

vent

ilatio

n im

poss

ible

, par

alys

eFi

nal a

ttem

pt a

t fac

emas

k ve

ntila

tion

Use

2 p

erso

n te

chni

que

and

adju

ncts

Plan

C: F

acem

ask

vent

ilatio

n

Sca

lpel

cric

othy

roid

otom

y

Plan

D: E

mer

genc

y fro

nt o

f nec

k ac

cess

Con

firm

trac

heal

intu

batio

n w

ith c

apno

grap

hy

If in

diffi

culty

c

all f

or h

elp

Wak

e th

e pa

tient

up

Post

-ope

rativ

e ca

re a

nd fo

llow

up

• Fo

rmul

ate

imm

edia

te a

irway

man

agem

ent p

lan

• M

onito

r for

com

plic

atio

ns•

Com

plet

e ai

rway

ale

rt fo

rm•

Exp

lain

to th

e pa

tient

in p

erso

n an

d in

writ

ing

• S

end

writ

ten

repo

rt to

GP

and

loca

l dat

abas

e

STO

P A

ND

TH

INK

Opt

ions

(con

side

r ris

ks a

nd b

enefi

ts):

1. W

ake

the

patie

nt u

p2.

Intu

bate

trac

hea

via

the

SA

D3.

Pro

ceed

with

out i

ntub

atin

g th

e tra

chea

4. T

rach

eost

omy

or c

ricot

hyro

idot

omy

This

flow

char

t for

ms

part

of th

e D

AS

Gui

delin

es fo

r una

ntic

ipat

ed d

ifficu

lt in

tuba

tion

in a

dults

201

5 an

d sh

ould

be

used

in c

onju

nctio

n w

ith th

e te

xt.

2015

Com

mun

icat

e th

e na

ture

of t

he e

mer

genc

y to

the

team

, cal

l for

sen

ior h

elp,

del

egat

e ta

sks

2

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Society. intubation guidelines working group. British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371

UNANTICIPATED DIFFICULT INTUBATION (DAS): Western General Hospital

DAS Airway Management Guidelines 2015

3. Cricothyrotomy

1. Use pillow to re-position head

2. Identify the cricothyroid membrane with the laryngeal handshake:-

Stab TubeBougieTwist

Medical Photography Service, NHS Lothian - MD - 11.04.2016

Communicate the nature of the emergency to the team, call for senior help, delegate tasks

3

FAILED INTUBATION, FAILED OXYGENATION (DAS): Western General Hospital

Communicate the nature of the emergency to the team, call for senior help, delegate tasks

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Society. intubation guidelines working group. British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371

4