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Unanticipated difficult tracheal intubation - during rapid sequence
                     induction of anaestheia in non-obstetric adult patient
               Direct                                         Any                                       Call
               laryngoscopy                                   problems                                  for help

Plan A: Initial tracheal intubation plan


 Pre-oxygenate                                                             succeed
 Cricoid force: 10N awake       30N anaesthetised                                                         Tracheal intubation
 Direct laryngoscopy - check:
    Neck flexion and head extension                               Not more than 3
    Laryngoscopy technique and vector                             attempts, maintaining:         Verify tracheal intubation
                                                                  (1) oxygenation with           (1) Visual, if possible
    External laryngeal manipulation -
                                                                      face mask
    by laryngoscopist                                             (2) cricoid pressure and
                                                                                                 (2) Capnograph
    Vocal cords open and immobile                                 (3) anaesthesia                (3) Oesophageal detector
 If poor view:                                                                                   "If in doubt, take it out"
    Reduce cricoid force
    Introducer (bougie) - seek clicks or hold-up
    and/or Alternative laryngoscope

                                failed intubation

Plan C: Maintenance of                        Maintain
oxygenation, ventilation,                     30N cricoid
postponement of                               force             Plan B not appropriate for this scenario
surgery and awakening


    Use face mask, oxygenate and ventilate
    1 or 2 person mask technique
    (with oral ± nasal airway)
    Consider reducing cricoid force if
    ventilation difficult                                                    succeed
                failed oxygenation
  (e.g. SpO2 < 90% with FiO2 1.0) via face mask



                                                                                 Postpone surgery
       LMATM                                                succeed              and awaken patient if possible
       Reduce cricoid force during insertion                                     or continue anaesthesia with
       Oxygenate and ventilate                                                   LMATM or ProSeal LMATM -
                                                                                 if condition immediately
           failed ventilation and oxygenation                                    life-threatening




Plan D: Rescue techniques for
"can't intubate, can't ventilate" situation

                        Difficult Airway Society Guidelines Flow-chart 2004 (use with DAS guidelines paper)

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Unanticipated difficult tracheal intubation - during rapid sequence induction of anaestheia in non-obstetric adult patient

  • 1. Unanticipated difficult tracheal intubation - during rapid sequence induction of anaestheia in non-obstetric adult patient Direct Any Call laryngoscopy problems for help Plan A: Initial tracheal intubation plan Pre-oxygenate succeed Cricoid force: 10N awake 30N anaesthetised Tracheal intubation Direct laryngoscopy - check: Neck flexion and head extension Not more than 3 Laryngoscopy technique and vector attempts, maintaining: Verify tracheal intubation (1) oxygenation with (1) Visual, if possible External laryngeal manipulation - face mask by laryngoscopist (2) cricoid pressure and (2) Capnograph Vocal cords open and immobile (3) anaesthesia (3) Oesophageal detector If poor view: "If in doubt, take it out" Reduce cricoid force Introducer (bougie) - seek clicks or hold-up and/or Alternative laryngoscope failed intubation Plan C: Maintenance of Maintain oxygenation, ventilation, 30N cricoid postponement of force Plan B not appropriate for this scenario surgery and awakening Use face mask, oxygenate and ventilate 1 or 2 person mask technique (with oral ± nasal airway) Consider reducing cricoid force if ventilation difficult succeed failed oxygenation (e.g. SpO2 < 90% with FiO2 1.0) via face mask Postpone surgery LMATM succeed and awaken patient if possible Reduce cricoid force during insertion or continue anaesthesia with Oxygenate and ventilate LMATM or ProSeal LMATM - if condition immediately failed ventilation and oxygenation life-threatening Plan D: Rescue techniques for "can't intubate, can't ventilate" situation Difficult Airway Society Guidelines Flow-chart 2004 (use with DAS guidelines paper)