ICU Cases · Airway management
Short case — cannot intubate, cannot oxygenate
A focused CICM short case on the cannot-intubate-cannot-oxygenate emergency — the endpoint of the Difficult Airway Society Plan D. The candidate declares the situation, abandons further attempts, and describes the scalpel-bougie cricothyroidotomy, while explaining why the lethal error is persistence and why NAP4 identified delayed front-of-neck access as a recurring cause of airway death.
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You are intubating a patient in the emergency department. Three optimal attempts at laryngoscopy with a bougie and a video laryngoscope have failed, a second-generation supraglottic airway does not seat, and optimised two-person face-mask ventilation is not moving the chest. The oxygen saturation is 72% and falling. The patient is bradycardic.[1]
State the principle first: this is cannot intubate, cannot oxygenate (CICO) — the endpoint of the Difficult Airway Society algorithm (Plan D) — and the only action that will save the patient is an emergency surgical airway, performed now.[1]
References4ShowHide
- [1]Frerk C, Mitchell VS, McNarry AF, Mendonca C, et al. Difficult Airway Society 2015 Guidelines for Management of Unanticipated Difficult Intubation in Adults. British Journal of Anaesthesia, 2015.PMID 26556848
- [2]Cook TM, Woodall N, Frerk C (eds) Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth, 2011.PMID 21447488
- [3]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.
- [4]Marino PL The ICU Book. 4th edition, Lippincott Williams & Wilkins, 2014.