So you’ll all probably be aware to the Difficult Airway Society (DAS) Guidelines for airway management. They centre around the need to have an airway strategy that is already determined for when an airway crisis occurs. As we’ve previously mentioned having those plans to hand makes stressful situations an awful lot easier by decreasing the cognitive load.
So DAS has just released an updated version of the guidelines for management of the unanticipated difficult intubation in adults, this is the first modification since the original guidelines in 2004. The full paper which support the new guidelines is open access and available here. This is a simplified algorithm which now includes unanticipated airway difficulties in both routine intubation and RSIs (hence it’s applicability to our ED cohort).
Being involved in airway management in the ED, even if you’re not the intubator, it is essential that we’re all au fait with the management plan during a crisis and that we are all singing from the same hymn sheet. So even if you think it’s not relevant to you I’d strongly suggest you burn this image on to the back of your retinas (NB all images in this post have been taken from the new guideline).
So the big change here from 2004 is the order of different oxygenation and ventilatory techniques with the supraglottic airway device (SAD) and facemark ventilation having switched places. So now it’s intubation>SAD>facemask>cricothyroidotomy. This seems pretty logical with the the progression through the algorithm moving to simpler/cruder techniques as the steps (and stress) progress.
What is also notable is the change in Plan D during the can’t intubate can’t oxygenate phase. Previously this had been the point for the clinician to decide when to perform a needle-cric with insufflation and passive exhalation or whether to perform the surgical cric. Now the guideline removes any need for decision making and moves on to performing the surgical cricothyroidotomy.
The flow chart is self explanatory but many of you will notice themes that have come up in FOAM a lot of times before with the infamous Levitan laryngeal handshake.
The full explanation of the laryngeal handshake is essential reading. It’s all to easy to look at the pictures and think you’ll do just that but have you thought about the side of the patient you’ll be standing on, how you’ll rotate the scalpel and what it will really mean to have a minimal movement strategy? It’s these intricacies that the paper goes into and they really help you practice and visualise the situation in order to be maximally prepared.
Hopefully you’ll be able to palpate the cricothyroid membrane and use the technique below…..
However if the cricothyroid membrane is impalpable then you’ll need to proceed to this technique below……
The full document is definitely worth a read, so make sure you take the time to read it. But until you get a chance being aware of the major points above will help align your practice with those around you.