Emerg Med Int, 2010 vol. 2010 pp. 826231
Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step
Sudrial, J; Birlouez, C; Guillerm, AL; Sebbah, JL; Amathieu, R; Dhonneur, G
We report a case of prehospital “cannot intubate” and “cannot ventilate” scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20 min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2 min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm.
Address: Prehospital Emergency Medicine Department, General Hospital Gonesse, 95500, France.
Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds 
As you know, this is my bug bear – the need for a well-thought out and articulated plan (I like the UK’s Difficult Airway Society algorithms), a checklist before attempting intubation and a verbal run-through with ‘cutoff’s’ for interjection (if SPO2 falls below 90% you will direct me to do X)…but most importantly a number of SIMPLE, RELIABLE and AFFORDABLE devices that you have trained with in elective situations
Probably more thought goes into this in the prehospital and EM arenas than for rural doctors – because our exposure to these events is often limited. But all the more reason for ‘occasional intubators’ to have drills and hands on training
“Relatively short” and 20 minutes aren’t exactly the same (perhaps they meant SI time, I still use English units). 5 devices seems like a lot to me too.
The LMA worked initially, so I wonder why it wasn’t left in place until they were certain they had optimized oxygenation. The LMA failed after two intubation attempts thru it, which sounds like it became unseated or as the authors believe the epiglottis came down front.
Very interesting conclusion from the authors given the case description, “It is now time to identify that the early performance of infraglottic (surgical) airway techniques may be life saving.”