Chapter 23. Emergency Airway Cart

Introduction

The emergency airway cart (Figure 23-1) is designed to be immediately available in the intensive care setting equipped with a variety of equipment that can be used to facilitate endotracheal intubation or alternative airway management approaches (ie, percutaneous airway) when standard approaches have failed.

Definitions and Terms

• ▪  ETT: Endotracheal tube.
• ▪  Difficult airway: The clinical situation in which a skilled operator experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both.
• ▪  LMA: Laryngeal mask airway.
• ▪  TTJV: Transtracheal jet ventilation.
• ▪  Surgical airway: Percutaneous tracheal intubation—techniques include cricothyroidotomy and tracheostomy.
• ▪  Retrograde intubation: Transtracheal passage of a wire through the vocal cords and into the pharynx where it is retrieved by operator, which is then used to guide (pull) the ETT into correct position in the trachea.
• ▪  Combined esophageal/tracheal tube: A tube designed so that the distal tip sits in and occludes the esophagus, while proximal orifices are used to permit tracheal ventilation.

Techniques

• ▪  Emergency airway cart equipment may include:
  • —Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic
  • —Laryngoscope
  • —Tracheal tubes of assorted sizes
  • —Masks of various sizes
  • —Tracheal tube guides, examples include (but are not limited to) semirigid stylets, ventilating tube changer, light wands, and forceps designed to manipulate the distal portion of the tracheal tube
  • —LMAs of assorted sizes
  • —Flexible fiberoptic intubation equipment
  • —Retrograde intubation equipment
  • —At least one device suitable for emergency noninvasive airway ventilation, examples include (but are not limited to) an esophageal tracheal tube, a hollow jet ventilation stylet, and a transtracheal jet ventilator
  • —Equipment suitable for emergency invasive airway access (ie, cricothyrotomy)
  • —An exhaled CO2 detector
• ▪  The American Society of Anesthesiology has published a difficult airway algorithm (Figure 23-2) that describes a pathway for handling unexpected problems with ventilation and intubation of the anesthetized patient, which is equally applicable to the intensive care patient.
• ▪  In the event of difficulties with ventilation:
  • —Consider or attempt placement of an LMA and ventilation.
  • —Call for help.
  • —Attempt endotracheal intubation.
  • —Attempt emergency noninvasive ventilation using:
    • • Esophageal/tracheal tube
    • • TTJV
  • —In the event that the preceding measures are unsuccessful, proceed to surgical airway.
• ▪  If mask ventilation is adequate and initial intubation unsuccessful.
  • —Attempt endotracheal intubation using alternative approaches including:
    • • Alternate laryngoscope blade
    • • Reposition head
    • • LMA placed as a bridge to intubation, where bronchoscopy is performed through LMA, and ETT threaded over bronchoscope
    • • Bronchoscopic intubation with ETT threaded over bronchoscope
    • • Retrograde intubation
  • —In the event that the preceding measures are unsuccessful, proceed to surgical airway.