Airway Planning and Preparation
My thoughts on this ...
- Here is the latest iteration of the Resuscitation Airway Carousel or "AirHenge": my attempt to summarize everything as simply as possible. It is a challenge to put the required essence down on paper, keep things simple but keep the message clear! Envy the #Vortex but that is for the unanticipated difficult airway. What's a way to encompass all resuscitation airways especially when time and resources are limited.
Plan ABC or Airway ABCs (Previously known to some as The Airway Carousel or AirHenge)
- This airway approach classifies all the different ways to manage the airway into plans A,B or C: three different pillars of airway management. Rueben Strayer @emupdates has a great algorithm that really gelled this idea for me.
- Plan C is a surgical cricothyrotomy method.
Plan A interventions are all the ways to secure a definitve airway of ETT by oral or nasal route. Each attempt is to be optimized to be the best attempt with the goal of DASH1A (Bill Hinckley's quality measure of definitive airway sans hypoxia on the first attempt. Consideration should also be added for best attempt, sans hypotension, sans hypoventilation especially in low pH metabolic acidoses, sans aspiration and limiting/avoiding multiple attempts which traumatizes/compromises the airway further).
Attempts are chosen at the discretion of the airway lead/team based on their familiarity, training, experience and the anticipated difficulty of the patient and situation. It includes bougie first direct laryngoscopy (DL) intubation, styletted ETT DL intubation, indirect or video laryngoscopy +/- bougie intubation etc. Attempt 1 is chosen to be the best optimized modality with greatest chance of success with the best operator present. Attempts 2 and 3 only occur if the patient is not becoming critically hypoxic (eg SpO2>92%) or else as part of a failed reoxygenation plan (failed BMV, failed SGA).
Plan B interventions are reoxygenation and reventilation methods: B1 is optimized BMV and B2 is some method of supraglottic airway. Failure of both these force the clinician to go either to plan A (recommend max 3 attemps in total) or C to rescue reoxygenate.My thinking about this ABC as a carousel however is that each airway intervention is equal and may be more appropriate at any given point in time or in any given clinical situation. Thus you may enter the carousel at any point and move between the different pillars of airway management (A, B or C) as indicated depending on what is happening. Achieve success (DASH1A+) or stabilization (ReOxygenation/Ventilation) with any of:1) Plan A (definitive airway by oral/nasal endotracheal intubation)2) Plan B (rescue breathing with reoxygenation/ventilation)3) Plan C (surgical airway via the neck: cricothyroidotomy or tracheostomy)
- To clarify one of the points in the above slide: if plan B succeeds or fails at reoxygenation and intubation is indicated, you should next consider either plan C or A in order to achieve definitive airway or rescue a plan B failure. If no first attempt at ETT (Plan A: A1) then can consider doing this before plan C surgical airway if your A1 plan is rapid, reliable and has good chance of success. Otherwise if there is "no time" ie continued hypoxia, then surgical airway via neck route should be done.
PLAN A: Definitive Airway by ETT
PLAN B: Rescue Breathing - reoxygenation and reventilation
PLAN C: Cut the Neck - Surgical Airway by Cricothyroidotomy/Tracheostomy
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