The nightmare comes when you can't intubate
and you can't ventilate. So, you make an attempt
to intubate. Can't get it in. You try to ventilate,
bag and mask can't ventilate. That is a disaster.
And you need help instantly. So scream for help,
get some people in to give you a hand. You cannot
waste any time in this situation. Try
a second time to get the patient
intubated. As I've said, reposition, get in the best
position. If this fails, immediately use
an airway adjuvant such as the LMA, and this would be
my personal choice. If ventilation is now possible,
and it often is after you've placed
an LMA, relax, stand back,
reoxygenate the patient, don't panic.
And then consider using the LMA as
a device through which you can intubate,
or consider using a video-laryngoscope.
If the patient cannot be intubated or ventilated,
and oxygen saturation is drawing, you
must go to a surgical airway. And to do
a crico-thyrotomy, you must
understand how to do it. Or to do jet ventilation,
you must understand how to do it.
So you must study those techniques BEFORE you get
into this trouble. It's too late to learn when you can't ventilate
and you can't intubate. Call for surgical help to do
a tracheostomy if a surgeon's available.
But in honesty, you should probably do some
surgical intervention yourself, either
a jet ventilator or a crico-thyrotomy. And then, when the surgeon
comes in, he or she can do a proper tracheostomy,
and take their time, and do it properly.
So an awake intubation is
a way to avoid all the unpleasantness that
I've talked about, about failed intubation.
But of course, in itself is not the most pleasant thing
in the world. And for a patient, when you first talk
to them about the fact that you're considering doing
an awake intubation, the response is often extremely
negative. You should have spent some time
on a simulator before trying
this on a patient. You should watch a senior colleague do
an awake intubation and try to learn from that individual.
And if you're in your training
program, this is an excellent
time to observe people who have more
experience with this kind of thing than you