Plan A, tracheal intubation
A maximum of three attempts plus one by a more experienced colleague. Each attempt should change something: position, blade, bougie, external laryngeal manipulation, or the operator. Repeating the identical attempt is how airway trauma and oedema are created.
Plan B, the supraglottic airway
A second-generation supraglottic device with a gastric port. Up to three attempts, and if it works, stop and think: wake the patient, proceed on the device, or intubate through it with a fibrescope. This is a moment for a decision, not a moment to keep pushing.
Plan C, face mask ventilation and wake up
Final attempt at face mask ventilation with an oral airway, two hands and two people, full relaxation. If oxygenation is achievable, waking the patient is nearly always the right answer.
Plan D, front of neck access
Cannot intubate, cannot oxygenate. Declare it out loud, because the words change the room's behaviour. Scalpel, bougie, tube through the cricothyroid membrane. The commonest reason this fails is that it was started too late.
Watch it done
Intubation tips and tricks
Positioning, the laryngoscope, the view, and what to do when the view is poor.
Source: ABCs of Anaesthesia · Watch on YouTubeWatch for
- Ear to sternal notch positioning
- The blade in the vallecula
- External laryngeal manipulation
Direct laryngoscopy: MICU fellows airway course, lesson 5
The ICU airway course lesson on the laryngoscope, watched by millions of trainees for a reason.
Source: Dr Gallagher's Neighborhood · Watch on YouTubeLaryngeal mask airway: MICU fellows airway course, lesson 4
Sizing, inserting and seating the supraglottic airway.
Source: Dr Gallagher's Neighborhood · Watch on YouTubeLaryngeal mask airway insertion
The insertion in three minutes, on a manikin, then confirmed.
Source: EM Cape Town · Watch on YouTube