Failed Airway

Cannot mask ventilate? cannot intubate? Try waking the patient up if possible. Otherwise, if there is no lightwand, fast-track, or fiberoptic around that buys the poor sucker a quick trip through the cricothyroid membrane with a 14 gauge angiocath. I guess if you really wanted to get creative you could always try a retrograde intubation, but the patient would probably be hypoxic as hell by the time you saw the guidewire.

We always have more than one ER doc on duty at a time, if one is having a difficult intubation, we'll grab another to come try, also we have some great RTs who have been known to get the tube when the ER doc hasn't. Use the fiber-optic occasionally. If no one in ER can get it, we overhead a code 100 and any available anesthesiologist comes. Worst case scenerio, we get out the cric tray and make our own airway!

Curious, is anybody using supraglottic devices to rescue the failed airway? I know this is quite common and effective in the EMS environment; however, is it utilized within the hospital? In addition, are docs using Gum Elastic Bougies and ELM for the difficult airways?

About 3 years ago, our institution initiated the airway cart. It's like a code cart with the drawers and all. All of the RSI meds are in there, the standard ETTs and laryngoscopes; in addition to rescue devices; including the LMA, combitube (or King LT), and a Rhino brand trach tray. We have the lighted laryngoscope and the lighted stylet. They usually go to a trach instead of a cric in the ER; but we do cric in the field. It's certainly less than optimal; as the previous poster stated, hypoxia has usually set in by then and it's badness.

On a difficult airway, anesthesia usually gets called if the patient can still be adequatley ventilated, rather than using a rescue device. However, more and more, the literature is supporting less attempts at ET intubation if difficult, and earlier use of the rescue airway. It's a paradigm shift, so it will interesting to see what transpires. When all else fails, a BLS airway still provides oxygen!