Can't Intubate, Can't Oxygenate (CICO)

[Aprz]

Awhile ago, I posted a thread on rapid sequence induction since I felt my paramedic program didn't go a good job covering (ie "You'll never do this... *click* *click* *click*...). Linuss recommended that I read Manual of Emergency Airway Management, which I am still in the middle of. One point that the book kept bringing up in the first few chapters is being prepared to have alternative ways to manage the airway, recognizing CICO, and to move onto a needle or regular cricothyrotomy. I was just browsing Facebook when I saw the Facebook group Prehospital 12-lead ECG post a video on "Can't Intubate, Can't Ventilate" (same thing as CICO) and the Tac-Med LLC posted below with a video of a cricothyrotomy.

Oddly Veneficus just posted his thoughts on videos and simulators,and I definitely believe we put too much emphasis on 'em and minimized or replaced doing the real thing, but I still think videos and simulators are a good adjunctive learning tool which is why I've decided to share what I saw on my Facebook here.

Video of Can't Intubate, Can't Ventilate: http://vimeo.com/970665

[YOUTUBE]http://www.youtube.com/watch?v=yfyQP4wNbcA[/YOUTUBE]

When do you think we should give up on intubation? Gut feeling? Number of attempts? Difficulty (Mallampotti and/or Cormack & Lehane)? Do you even know the Mallampotti and Cormack & Lehane scale?

Do you have a backup plan for when plan A fails? Do you have alternative airways ready? Different sizes ready? Do you know different techniques to insert these airways? Is this feasible in the prehospital setting?

In the video, the anesthesiologists and ENT failed to recognize CICO, but the nurses did recognize it, informed the ICU, and grabbed the cricothyrotomy kit, yet they never spoke up to actually discontinue attempting to insert an endotracheal tube even after 30-something minutes! How do you think somebody would react if somebody equal or lower in training/certification said to you "This isn't going to work. It's cricothyrotomy time"? What are ways that we can approach somebody who is equal or higher training to us who are tunneled vision? A lot of people also mention that they'll speak up if somebody is doing something detrimental to the patient, but to me, it seems like people rather wait until after everything happens before they speak up (even if it's detrimental to the patient).

Relevant Links:

Manual of Emergency Airway

Rapid Sequence Induction HOWTO

"I saw it on TV..."

Prehospital 12-Lead ECG (ems12lead) Facebook Group

Tac-Med LLC Facebook Group

 

[Dwindlin]

Going to disagree on the simulator part. Some events have become so rare that without sim. you would never have any chance to "experience" the event. MH management in the O.R. is one big one that comes to mind.

I like videos myself. First thing I did before trying a new procedure for the first time was youtube it.

When is it time to move on? Tough to say, very patient dependent. My personal starting point is if I can't get it after taking two shots, I try bougie. If still nothing at that point and I can't bag I go immediately to rescue device, if that fails for me its scalpel time. I think the important part if airway management is have a CLEAR plan before you even think about starting.

For the last part, speak up. Everyone gets tunnel vision from time to time. You can kiss and make up later if necessary. All that should matter in the moment is the patient.

 

[Handsome Robb]

That's a sad case about the woman in the CICV case in the OR.

Also, that crich video is interesting, I've never actually seen a video of a live one! Thanks Aprz!

Going to disagree on the simulator part. Some events have become so rare that without sim. you would never have any chance to "experience" the event. MH management in the O.R. is one big one that comes to mind.

I like videos myself. First thing I did before trying a new procedure for the first time was youtube it.

When is it time to move on? Tough to say, very patient dependent. My personal starting point is if I can't get it after taking two shots, I try bougie. If still nothing at that point and I can't bag I go immediately to rescue device, if that fails for me its scalpel time. I think the important part if airway management is have a CLEAR plan before you even think about starting.

For the last part, speak up. Everyone gets tunnel vision from time to time. You can kiss and make up later if necessary. All that should matter in the moment is the patient.

I agree with everything here. There are some real key points that you bring up.

Having a plan before you start and have the equipment for your plan set up. You can have this "perfect plan" in your head but when something goes wrong and you're trying to dig through your bags to get equipment you need for plan b or c or d you're already behind the curb. You don't have to have all your backup tubes/devices opened (I'm sure logistics will appreciate you not blowing through a handful of airway devices for every airway attempt "just in case" but have the package out, in order of your planned progression and be organized about it. It's easy to grab the next size down, tear the package, drop the stylet that you're using into the new tube and go for another attempt. Voice what you're doing, people can't read minds. You don't have to verbalize it step by step but a quick run down so everyone is on the same page.

My best friend's father always used to tell the two of us "Always remember the six (or seven) P's. Prior proper planning prevents (piss) poor performance." His point was always some life lesson he was trying to teach us but it's definitely a statement that applies to medicine as well.

Don't keep trying the same thing, I'm guilty of this one myself. Medicine is a science. You experiment in science. If you remember basic high school, even middle school science to experiment you have to change a variable. If your technique isn't working you need to change something. Backing out because you can't visualize your landmarks then trying again without making adjustments is just setting yourself up for failure. Patient positioning and blade selection are the two big ones that come to mind. Have you used external laryngeal manipulation? Did you pad behind the shoulders? Is there a FBAO we aren't recognizing? Don't be afraid to ask for a second opinion, even if it's not another provider of your same training they still might be seeing something you're not. If there's another provider capable of placing advanced airways you're doing your patient a disservice, a potentially fatal disservice, if you're too "big" to ask for help or say "I can't see anything, will you take a look please?"

As far as when it's time to "jump to the bottom of the algorithm" if you will, I second it being patient dependent. You can't make hard and fast rules that work in every situation, just look at protocols! :lol:

 

[NomadicMedic]

Our RSI algorithm is three attempts max, 2 by one provider, before moving on to a rescue airway or a cric. I tend to use a bougie on EVERY tube, because it increases my chances of first pass success. So, I've already moved down the list. Frankly, I'm not afraid to move to a rescue airway if it looks like I won't successfully place an ET tube on the second attempt.

We use the "quik-trac" as our cric kit and while I've had it out, I haven't had to use it. Yet. I'm certainly not so foolish as to think I'm going to have continued ET airway success.

I believe the key in knowing when to move on is the realization that you're not going to get the tube. Too many paramedics (and docs) seem to think "the very next try" will be the winner. Kind of like playing a slot machine. Limiting the tube attempts to 3 gives you a hard stop point to reevaluate your airway strategy and move on to plan C,D or E. Obviously, we'd all hope the decision would be made sooner in a CICV case.

 

[blindsideflank]

i think the manual refers to it as cant ventilate cant oxygenate. I like this wording better.

i believe the manual also states that you shouldnt retry an intubation unless something will be done differently that you expect to work (makes sense). Perhaps sweeping the tongue better, BURP, bougie, different clinician to attempt, different laryngoscope etc. once you run out of these then crich. if you are killing the pt then i like 2 attempts, another clinician try once while you prep for crich then do it. (all these case assume cant vent cant oxygenate).
this is assuming your rescue airway had been ruled out early (perhaps before intubation was attempted or after one or two tries at intubation)

 

[Handsome Robb]

Random but blindside's reference to the manual made me want to ask a related question if it's alright with Aprz...

What do people's protocols say about number of attempts? Our's say two per provider. Seems reasonable, but at the same time that doesn't mean all 6 people on scene get two attempts. PIC does two, rescue airway attempt, BLS if it's working, if not then cut would be my personal thought process.

For terminology's sake: An attempt, as defined by my protocol is "the passing of the tip of a blade or King Airway past the teeth."

Does anyone use rescue airways as their first line with ETT as a backup or when a SGA is contraindicated? We do. Don't ask, not something I'm happy about. Bougies are also required on any intubation attempt, not really a bad thing but like n7 put it; you've already skipped plan A with this style.

 

[Aprz]

I briefly looked over my advance airway protocols, and I didn't see any limit to number of attempts on adults, however, it does say we have to document number of attempts, and it considers one attempt when the end of the endotracheal tube passes the teeth. For pediatrics, it says that we can try once on scene and while transporting. I would've thought the magic number was three, but I guess not. In my area, seems like providers are moving away from endotracheal tube even in cardiac arrest and going straight for the king airway while in a county nearby they are putting a lot of emphasis on tubing patients so we can get an EtCO2 to monitor chest compression effectiveness and see if we get return of spontaneous circulation without actually having to waste time to check for a pulse.

 

[Rykielz]

There's no limit on the number of attempts you can try where I work; the county has decided to give us the right to make that judgement. Generally it's 2 attempts and then you go to a King airway. With me personally, it's one attempt unless there're extenuating circumstances and I'm 100% sure I can get it in. Regardless of what you do, you need to always be cognizant of the standard of care and thinking about what is best for your patient. Most counties that I know of do not have the option of cricothyrotomy so the needle cric (if they have it) is the last attempt should all else fail.

 

[Veneficus]

In some industries, like the fire service, there is what is known as the immediately dangerous to life and health event. (IDLH) I think it is absolutely applicable to medicine and especially in surgery or critical care.

Basically anyone, in the name of safety, can call a halt to an intervention underway.

This needs to be encouraged and nonpunitive. Because of the focus on the complex events going on in these medical environments, any person at any given time can be so focused on what they are doing that they lose sight of the big picture.

One of the reasons there are "officers" in every industry is to keep the big picture in mind.

It shouldn't matter if the janitor calls attention to it. Sometimes the person not involved is the only one who can see the totality of the situation.

It is not an ego slap, it is a critical observation in a dynamic environment where the stakes are life and death.

Even if the person calling the stop is wrong, it permits reflaction and refocusing.

I think SOPs need to be in place for this at every healthcare institution from EMS to the closed critical care units in the hospital.

I also think peer pressure in the name of safety needs to be the norm. If anyone takes issue with a nurse or tech pulling the "safety switch" it is the person who takes issue that needs to be the focus of re-education.

I specifically think that nurses need and should be comfortable being direct when something is so very wrong. I would also think any doctor worth their position would respect and agree if a nurse did such.

(I have noticed OR nurses are particularly docile personalities except towards medical students everywhere I have been.)

But I would like to see them speak up for safety with the same passion they do when a medical student breaks a sterile field or technique.

Onto when to go to the backup.

It is not an easy answer there are many variables. But here are some things I think would help:

Anytime you are preparing to RSI or use anesthesia/paralytics in any capacity, you need to be mentally prepaired and willing to do an emergent cric. You need to have the kit or knife or whatever readily at hand. (maybe not opened, that would be wasteful)

We have to be honest with ourselves. Did you see the cords on the first attempt?

If the answer is "no" and you do not regularly intubate difficult patients (like every week) then that should imediately go to backup airway. There really isn't anything further to discuss.

If there was a problem with equipment or operator error, then perhaps a second attempt is warrented.

In the CICO event, having other providers try is not something that should be happening.

I would say a total of 2 tubes is the most that should be tried. Scoring systems do not really matter, it doesn't matter if it is m1 or m4, if you can't intubate or oxygenate, the difficulty of the task is beyond you for whatever reason. Sure we can say anyone should be able to intubate an m1, but "shoulda, woulda, coulda," is a discussion for later.

One of the reasons I am so against non-experts teaching emergency surgical procedures, is because there is loss of the surgery mindet. One of the hallmarks of surgeons, for good or for ill, is to imediately decide and initiate the most aggresive treatment as a first option. It is actually taught during their residency training. (though most would not recognize it unless it was pointed out)

"BLS before ALS" or "escalating treatments" probably creates a bit of a mental block about moving to such decisive action. That and lack of regular training.

If you look at firefighters, military, Police, etc, who do heroic things and are asked about it later, they usually say something about "I wasn't thinking, I was just doing what I was trained for."

How often do you receive surgical cric training? Could you recall the steps in your sleep like BLS or ACLS? Can you recite the local landmarks? Do you know the common anatomical variances? When was the last time you even opened up that equipment?

See the problem?

Knowledge and training removes fear and the mystique of procedures.

A cadaver is probably a better choice than a doll for simulation though. For a cric, there is a world of difference.

If you really must, watch it on youtube and then go to the butcher shop and ask for a trachea and lungs from a cow or pig. That will teach you a lot. They usually give them away for free. (much cheaper than a doll) but I always like to give the folks there some money to say "thanks" and give their business a plug when teaching.

Always ask "what next?" when deciding on a procedure. Usually it will follow with: "if it works I will..." or "if it doesn't work I can..." and be ready for both.

 

[usalsfyre]

Just a quick note. I haven't been involved in any TRUE CI/CO situations. I have been around a couple of "near-misses" though. "Attempts" weren't in the thought process, it was more like "their sats still aren't really good lets tube them quickly, oh cr@p I can't get the tube bag them up, oh f*&?! I can't bag them where's the King and/or a scalpel"

Can't intubate is what's being referred to here and while its still a bad situation its not nearly as huge of an issue.

 

[Veneficus]

Just a quick note. I haven't been involved in any TRUE CI/CO situations. I have been around a couple of "near-misses" though. "Attempts" weren't in the thought process, it was more like "their sats still aren't really good lets tube them quickly, oh cr@p I can't get the tube bag them up, oh f*&?! I can't bag them where's the King and/or a scalpel"

Can't intubate is what's being referred to here and while its still a bad situation its not nearly as huge of an issue.

But as you pointed out, can't intubate comes well before can't ventilate, and it seems only logical that is where the intervention to prevent a bad turn of events needs to take place.

Discovering that you can't ventilate is late in the game.

 

[Av8or007]

Check out the EMCRIT CricCon concept. Intersting way of putting it, but it basically says that you should be ready to do a cric for any potentially difficult airway.

emcrit.org/wee/bougie-prepass-and-criccon/

 

[Veneficus]

Check out the EMCRIT CricCon concept. Intersting way of putting it, but it basically says that you should be ready to do a cric for any potentially difficult airway.

emcrit.org/wee/bougie-prepass-and-criccon/

I have heard that somewhere before???:unsure:

Oh yea, I remember now...

Anytime you are preparing to RSI or use anesthesia/paralytics in any capacity, you need to be mentally prepaired and willing to do an emergent cric. You need to have the kit or knife or whatever readily at hand. (maybe not opened, that would be wasteful)

 

[Carlos Danger]

I read Manual of Emergency Airway Management, which I am still in the middle of.

Good on you. When I was early in my career I studied that book cover to cover several times. At one point I had large parts of it virtually memorized. And there's no doubt in my mind it contributed to my airway skills in a significantly positive way. A really excellent book; I can't recommend it highly enough.

As far as when it's time to "jump to the bottom of the algorithm" if you will, I second it being patient dependent. You can't make hard and fast rules that work in every situation, just look at protocols! :lol:

Protocols work best in situations like this, though. We all love to think we are airway experts, and that "I know when to try something else", but the reality is that airway management is at the same time the most difficult/critical thing we do in the field, and one of the rarest. Left to our own devices (i.e. just doing what we think makes sense, rather than following a protocol), most of us do not react to tough airway situations as slickly as with as great judgement as we'd like to think.

It is things that like that protocols are most important for.

I believe the key in knowing when to move on is the realization that you're not going to get the tube. Too many paramedics (and docs) seem to think "the very next try" will be the winner. Kind of like playing a slot machine. Limiting the tube attempts to 3 gives you a hard stop point to reevaluate your airway strategy and move on to plan C,D or E.

Exactly. 3 attempts is actually quite generous in a sick patient, IMO. As you say, it's very easy to keep thinking "Just one more try....I'll get it this time!"

i believe the manual also states that you shouldnt retry an intubation unless something will be done differently that you expect to work (makes sense). Perhaps sweeping the tongue better, BURP, bougie, different clinician to attempt, different laryngoscope etc. once you run out of these then crich.

The problem with that reasoning is that there are endless things that you can "keep trying".

Your first attempt needs to be your best attempt. That means the best positioning possible, BURP, etc the FIRST time you try....not waiting until you've missed a time or two to try those things. Continuing to swap blades and positions is not an acceptable strategy.

Sure, you can make the argument that "as long as the pt's Sp02 is fine, why not keep trying?" and there's some validity in that. But remember this is a non-NPO patient who can easily aspirate and you are probably driving your head-injured patient's ICP through the roof with each attempt. And most importantly, things can change quickly. I'd say after a try or two, drop your SGA before something happens and things go south.


I think the biggest problems with prehospital RSI/intubation are

• Lack of training / experience, and
  
• Poor BLS airway skills.

I know we paramedics get tired of hearing "BLS before ALS" and "Your BLS airway skills need to be stronger", but it really is true.

If you can adequately mask-ventilate a patient, you increase the safety of RSI to the point that the only real risk is aspiration. As long as you can mask, then the patient is never in danger. It changes the entire dynamic of an RSI sequence significantly.

We all "know" that, but I don't think many of us really understand that.

Laryngoscopy skills, knowing how to use a bougie, knowing all about positioning and BURP, etc....that's all good stuff, but the most important stuff by far is being good at mask ventilating, and really knowing how / not being afraid to cric.

 

[mycrofft]

This raises the age old question, why don't practitioners go to the most effective measure first, even if it involves knocking out the pt and sliding a tube down their airway, when the faster and less-invasive measures have a higher chance for inefficacy which leads to death or loss of brain cells?

Courses not teaching why are lacking. Graduates not considering it in advance, as is being done here, are lacking as well.

So, WHY don't you just introduce yourself, get permission to treat, determine need to address airway/ventilation, then shoot them with the curare dart and tube them bedfore any trouble starts? (Of course, you need to put them on a spineboard too).

 

[mycrofft]

Hint: recall the story about the mechanic who only has a hammer, and everything needing a good bash?

 

[blindsideflank]

The problem with that reasoning is that there are endless things that you can "keep trying".

Your first attempt needs to be your best attempt. That means the best positioning possible, BURP, etc the FIRST time you try....not waiting until you've missed a time or two to try those things. Continuing to swap blades and positions is not an acceptable strategy.

agreed, thats why i added "unless something will be done differently THAT YOU EXPECT TO WORK" if not then why try again.

most of us are arguing the same thing in different words, clinical judgement not protocols

and the idea of make your best shot your first shot is often applied to paralytics, something we should really worry about with our lack of skills. I have been with anesthesiologists that believe emerg physicians shouldnt be touching them. (rediculous, but interesting point of view)

 

[mycrofft]

Applying old school paralytics.

Look at those primitive airways!