Emergency Tracheotomy

Can’t Intubate and Can’t Ventilate


Although it doesn’t happen often, it’s possible one can be faced with a situation where they’re unable to intubate and unable to ventilate a patient. If this happens, here are a few things you may want to consider:

  • Unsuccessful first look laryngoscopy (with or without intubation)? Revert back to the BVM. Are you able to ventilate and oxygenate with the BVM? Are you able to keep the patient’s Sp02 above 90%? If it’s below 90%, is it at least increasing with your ventilations? If yes, this may be sufficient.
  • If after your failed intubation attempt you’re still unable to achieve effective ventilations, go back to the basics and sequentially perform the approach to a difficult BVM:
  1. Reposition airway
  2. Consider foreign body obstruction
  3. Consider alternative mask size
  4. Insert an OPA and/or NPA
  5. Perform two-person BVM
  • If you’re now able to ventilate with the BVM you have time. Does the patient still need to be intubated? If yes, consider a second larygoscopy attempt and use a bougie for any attempt at intubation. If your second attempt fails or you elect to not attempt another intubation, continue to ventilate the patient with good BVM technique and consider the insertion of an EGD like an LMA or a King-LT. Consider possible difficulties of placing and ventilating with an EGD like mouth opening limitations, obstructions at or below the glotic opening, disruption / distortion / displacement of the airway, and stiff lungs.
  • IF all of the above fails (i.e. you are still unable to intubate and unable to ventilate the patient) then it’s time to perform ventilations by accessing the trachea through the crico-thyroid membrane. This can be done in many ways including a surgical airway or use of a specialized device such as “QuickTrach”. Below is a quick example a tracheotomy pulled from the American Society of Anesthesiologists website:


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