Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Resusciation and Anaesthesia
Resuscitation and Preparation for Anaesthesia and Surgery
Management of emergencies and cardiopulmonary resuscitation
Other conditions requiring urgent attention
Intravenous access
Fluids and drugs
Drugs and resuscitation
Preoperative assessment and investigations
Anaesthetic issues in the emergency situation
Important medical conditions for the anaesthetist
Practical Anaesthesia
General anaesthesia
Anaesthesia during pregnancy and for operative  delivery
Pediatric anaesthesia
Conduction anaesthesia
Specimen anaesthetic techniques
Monitoring the anaesthetized patient
Postoperative management
Anaesthetic infrastructure and supplies
Equipment and supplies for different level hospitals
Anaesthesia and oxygen
Fires, explosions and other risks
Care and maintenance of equipment



Don’t panic. Have a plan.

Expected difficult intubation

Before every intubation, but especially if you expect difficulties, have ready (or know the location of ) emergency tools, such as:

:: Intubating stylet
:: Long bougie
:: Laryngeal mask airway (LMA).

The LMA can often be passed to maintain the airway when intubation is impossible. If the stomach is full, as is often the case in emergencies, you will have to balance the risk of regurgitation with the LMA in place against the same risk during further attempts at intubation, or complete failure to intubate.

Unexpected difficult intubation

If you cannot see the larynx clearly enough to get the tube in, possible remedies include:

:: Reposition the head – try a pillow under the head
:: Pass an intubating bougie or use a stylet to make the tube more curved
:: Hold the laryngoscope to give upward traction
:: Reposition the blade if the tongue is blocking the view
:: Change the blade:
If it is too big, you look down the oesophagus
If it is too small, you cannot lift the epiglottis
:: Give further relaxant or deeper halothane anaesthesia to abolish reflexes.

Only if you can remedy one or more of the above problems should you try again, but remember to:

:: Call for help
:: Stay calm
:: Re-oxygenate (mask and airway) and watch the oximeter
:: Maintain cricoid pressure, if needed
:: Consider the need for more atropine.

If intubation still fails, stop any further attempts at intubation. Remember that it is an abuse of the patient to have several people lining up to try their skills at this “interesting” case.

There are then the following two possible courses of action.

:: If the operation must now go ahead under general anaesthesia, for example, in haemorrhage, ruptured uterus, long standing intestinal obstruction:
Try inserting an LMA
If LMA insertion is not possible, try an oral airway and inhalation anaesthesia with a face mask
If neither of the above are possible, give ketamine with oxygen by face mask
Maintain cricoid pressure if there is a regurgitation risk.
:: If the operation can be postponed:
Allow the patient to wake up, while maintaining oxygenation and
ventilation as best you can
Use regional or spinal anaesthesia or abandon the procedure and refer
the patient.

Do not make your ability to intubate more important than the patient’s life.

Endotracheal tube in the oesophagus

Apply the ten tests of correct tube placement on page 13–2. If in doubt, remove the tube and follow the steps above.

No ventilation of the lungs

If you thought intubation was successful, but you cannot ventilate the lungs, think of the following:

:: Oesophageal tube
:: Tube is blocked
:: Patient circuit wrongly connected or configured
:: Obstruction in the trachea
:: Tube is against the wall of the trachea or tube cuff has herniated: let down the cuff.

Only if you have tested and eliminated the above, consider:

:: Severe bronchospasm
:: Wrong drug administration: e.g. neostigmine
:: Aspiration of gastric contents
:: Tension pneumothorax
:: Pulmonary oedema
:: Infection, such as bronchitis or pneumonia.

Vomiting and regurgitation

Seeing stomach contents in the unprotected airway of an unconscious patient is probably the worst thing that can happen in the practice of anaesthesia. Do not let this happen to you.

Aspiration of stomach contents into the lungs is often a terminal event for the patient. However, regurgitation is both predictable and avoidable. This is the moment when you must act with the greatest speed. Options are:

:: Tilt the bed head down, continue cricoid pressure (or put it on) and suck away the vomitus with the biggest, most powerful rigid sucker you can find
:: Turn the patient on to the side and suck.

The choice will depend on which can be done fastest, according to the workings of the table, the available manpower and size of the patient. In either case, intubation is recommended as soon as possible to protect the airway and also to suck down the trachea, both for diagnostic and therapeutic reasons.

Give steroids, antibiotics and bronchodilators if aspiration is suspected. The pulse oximeter may show desaturation and the lungs may become stiff to inflate.


Top of Page



















  Kep Points  
If you plan to intubate, always have a backup plan in case of failure

Don’t persist with multiple
attempts just to prove you can do it.