Failed intubation

There must be a drill if intubation proves impossible. This can be predicted by examining the patient. The principles are as follows:

1. recognize early that there is difficulty;

2. maintain oxygenation;

3. prevent pulmonary aspiration of gastric contents;

4. call for more experienced help;

5. proceed to alternative methods or routes of oxygenation and ventilation.

It is important to recognize when there is likely to be difficulty as prolonged attempts at unsuccessful intubation may cause more trauma to the airway and the patient may become hypoxemic. Inserting an oral airway and gentle hand ventilation with 100 per cent oxygen with cricoid pressure still applied may keep the patient safe while alternative strategies are explored.

The laryngeal mask is available to assist in ventilating patients in these circumstances. If employed, it should not be relied upon to protect the patient against pulmonary aspiration, but should be used as a temporary measure to allow ventilation.

If intubation fails, there are three possible procedures.

1. Call for more experienced help.

2. If help is not available, abandon further attempts at intubation, turn the patient on to his or her side, and maintain patient recovers from neuromuscular blockade and anesthesia.

3. If the patient's clinical state before the attempted intubation was so poor that this last alternative is impracticable, cricothyroid puncture with an intravenous cannula, at least to maintain oxygenation, could be lifesaving.

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