Can't Intubate, Can't oxygenate (CICO) The new terminology What is the Military Experience What is the Civilian Experience What is your role.

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2 Disclaimer The views in the presentation are the author's, and do not reflect the views of the Department of Defence I am a full time Australian Defence Force Procedural Specialist (Anaesthetist)

3 Can't Intubate, Can't oxygenate (CICO) The new terminology What is the Military Experience What is the Civilian Experience What is your role.

4 Can t Intubate Can t oxygenate - CICO Replaces can t intubate can t ventilate is an airway emergency : failure to establish oxygenation = death Response to a CICO situation is a Individual TEAM- system responsibility Ownership of Preventable Death Service, Commanders and health providers

5 Military Context Leading Preventable Causes of death Haemorrhage Tension Pneumothorax Airway obstruction- 6% Tactical Combat Casualty Care TCCC Treat the casualty, prevent further casualties and complete the mission Limited published incidence of overall Cant Intubate Can t Oxygenate incidence on operations pre hospital gap

6 Military Aetiology of Threatened Airway Military Factors- Injury IED / Bomb Gunshot Rocket / Grenade Blast injury Burn Inhalation Head / face / neck Environment (Threat / Light/ confined space) Protective Equipment Individual and transport SOP s Patient Shrapnel factors Pre-existing Anatomical causes (Civilian Vs Military) Airway Management Training and competency (procedures and protocols) Equipment + Drugs

7 Military Specific Challenges TCCC: Combat first aiders - Medics Casevac System System Threat Environment ground / air / sea Health provider capability scope of practice, training, currency, recertification Combat first aider / medic / advanced medic / Paramedic / MERT Injuries to / rotations of health providers Platform Specific challenges Road Safety, space and speed Air- RWAME Fixed Wing, Unmanned Veh? Sea- boat/ RWAWE Health Facility Role 1/ 2 / 3

8 Afghanistan- Helicopter based pre-hospital medical capabilities

9 Case reports Military Literature US Committee on Tactical Combat Casualty Care (CoTCCC) US RANGER Pre Hospital Trauma Registry Canadian Forces US Department of Defence Trauma Registry (DoDTR)

10 Retrospective analysis of 3yr period OEF - surgical cricothryoidotomies battlefield/ aid station 72 attempts at surgical airway in 20,066 casualties (WIA/ KIA) 26% Unsuccessful Too high/ low Parallel/ false tracts Oesophageal Specific Training to address deficiencies

11 US Rangers- Data Casualties= 419 Fatalities = 32

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13 Combat Casualty Care Working Group: Supra-glottic Airway not suitable facial injuries or the un-obtunded pt Surgical cricothyrotomy recommended as the definitive airway Migration of cuffed ETT down Right Main Bronchus x2 hypoxia/ misdiagnosis of Tension Pneumothorax commercial Surgical airway kit to prevent this

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16 Civilian Experience Evolving Pre-hospital Systems Pre-hospital advanced airway management Training and clinical placement in hospitals Helicopter / Mobile Paramedic back up Treatment and Drug Protocols Equipment Video laryngoscopes Airways- supraglottic Hospital systems Airway Interventions largely doctors (in Australia, nurse anaesthetists US)

17 Civilian Experience- 4 th National Audit Project (NAP4) Examined prospectively the occurrence of serious airway complications (resulting in death, brain damage, surgical airway, or unexpected intensive care unit (ICU) admission) in anaesthesia, ICUs, and emergency departments of all the National Health Service (NHS) hospitals in the UK over 12 months

18 NAP 4 deaths summary Anaesthesia 133 events One event per 22,000 cases 13 deaths ICU- 36 events Tracheostomy events 50% 16 deaths Emergency Department- 15 events events at intubation 3 deaths

19 NAP4- Summary Analysis of the cases has identified repeated gaps in care that include: poor identification of at-risk patients (Obesity); poor or incomplete planning (Plan A, B,C,D); inadequate provision of skilled staff and equipment to manage these events successfully (ICU/ ED); delayed recognition of events; and failed rescue because of lack of interpretation or lack use of capnography. British Journal of Anaesthesia 106 (5): (2011) Advance Access publication 29 March doi: /bja/aer059

20 NAP4- Outcome of Rescue Techniques A Surgical Airway attempted in 80 of 184 cases (43%) Anaesthesia: 58-4 died (2 failure surgical airway) Induction 52%, maintenance 18%, emergence 16%, recovery 14% 29 of 58 Tracheostomy first choice - 11 in CICO, 2 Died 29 cricothyroidotomy 7/19 narrow bore needle successful (36%) - rescued by surgical tracheostomy 4/7 large bore needle successful (57%) - rescued surgical tracheostomy All 3 surgical cricothyroidotomy successful

21 NAP4- Outcome of Rescue Techniques Anaesthetist: 9 of 25 attempts successful airway rescue (36% success rate ) 11 rescued by surgeon performed tracheostomy 1 by 2 nd anaesthetist - percutaneous tracheostomy 3 by intubation 1 died

22 CICO : What is Your Role? Commanders /Teams / Individuals Initial Training and Certification EMST, MILAN Individual / team / unit / collective training Clinical Placement and Simulation Health Manual Volume 7 and 8 ANZCA, CICM and ACEM Standards Primary Critical Care Manual ADF Treatment Protocols, Drug Protocols

23 Recognition of CICO >3 attempts at intubation? Failed to oxygenate with supraglottic devices e.g., LMA? Failed Bag Mask Oxygenation Oxygen saturations persistently low? < 90 All above = CICO Situational awareness

24 EMERGENCY PROTOCOL CAN T INTUBATE, CAN T OXYGENATE (CICO) IS THIS IS A CICO SITUATION? >3 attempts at intubation? AND Failed to oxygenate with supraglottic devices e.g., LMA? AND Oxygen saturations persistently low? CALL FOR HELP Airway Experienced Doctors/Assistants: Anaesthetist/ ENT/ ICU/ ED/ Anaesthetic nurse YES NO REVIEW again in 1 min ALLOCATE ROLES AIRWAY TEAM DOCTOR PERFORM CANNULA CRICOTHYROIDOTOMY/TRACHEOTOMY remember: pillow out, extend neck, stabilise trachea SUPPORT ROLES Assistant 1 Assistant 2 Scalpel + Bougie (frova) Is the neck anatomy palpable? yes OXYGENATE & stabilise Use self-inflating bag FAIL no Scalpel + Finger + Cannula FAIL OXYGENATE & stabilise Use jet insufflation kit insufflate for 4s then wait till max sats drops 5% then insufflate for 2s SUCCESS OXYGENATE & stabilise Use jet insufflation kit insufflate for 4s then wait till max sats drops 5% then insufflate for 2s Railroad 6.0 cuffed ETT Seldinger technique: Melker 5.0 cuffed ETT Consider waking patient With permission A.Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) Critically Obstructed Airway Workshop. Contact smsc@nsccahs.health.nsw.gov.au FAIL

25 Airway Goal and Team Oxygenation and establish ventilation Emergency Front of Neck Access (New DRAFT DAS guidelines ) Surgical Cricothyroidotomy Cannula cricothyroidotomy [only if skilled] Airway Providers Medics, Nurses, Doctors S is for Surgeon Assistant(s): get equipment ready

26 Airway Provider (s) IS the Neck anatomy palpable? YES Scalpel + Bougie (frova) Railroad 6.0 cuffed ETT FAIL Oxygenate Stabilise Proceed (Vs Wake Up) NO Scalpel + Finger + Cannula Seldinger technique : Melker 5.0 cuffed ETT

27 CICO: Summary Lessons Learned and not unlearned Pre-hospital and hospital life saving airway intervention Recognition and Communication within Team Remind.. Execution graded escalation Who what where when and why Clinical Governance, Protocols and Procedures Difficult airway and CICO Strategy Technical skills Initial training, skills refresher / maintenance, team training, CERTIFICATION Equipment- instruments, consumables, drugs, packs

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