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Crisis Card

Cannot Intubate, Cannot Ventilate

Oxygenation is paramount. Default to whatever works. Surgical airway last but don't delay.

Call for help · Get the difficult airway cart · Prepare for surgical airway

Recognize

  • Failed mask ventilation AND failed laryngoscopy
  • Falling SpO₂ despite attempts
  • Bradycardia heralding hypoxic arrest

Doses

Sugammadex (post-roc)
16 mg/kg IV
May restore spontaneous ventilation
Cricothyroid tube
6.0 cuffed ETT over bougie
Apneic O₂
Nasal cannula 15 L/min
Provides minutes of safe apnea

Sequenced Actions

  1. 1
    Call for help — early
    • Second anesthesiologist
    • Surgeon at the head of the bed
    • ENT / general surgery for surgical airway
    • Get the difficult airway cart
  2. 2
    Optimize mask ventilation
    • 100% O₂, two-handed mask + jaw thrust
    • Oral + nasal airway
    • Reposition: sniffing position, head extension, ramp obese patients
    • ↑ PIP up to 25–30 cmH₂O if needed
  3. 3
    Place a supraglottic airway (LMA)
    • Single best rescue maneuver
    • Use 2nd-gen LMA (Supreme, ProSeal, i-gel)
    • Adequate ventilation through LMA buys time
  4. 4
    If LMA works
    • Maintain SGA, oxygenate, then decide:
    • Wake patient up if elective
    • Intubate via SGA with fiberoptic if surgery must proceed
    • Proceed with surgery via SGA if low-risk
    • Convert to surgical airway electively if needed
  5. 5
    If LMA fails — CICV
    • Call out "CANNOT INTUBATE, CANNOT VENTILATE" loudly
    • Proceed to emergency front-of-neck airway — DO NOT WAIT
    • Concurrently: maximize O₂ via nasal cannula (apneic oxygenation)
    • If sugammadex available and ROC given: 16 mg/kg sugammadex to attempt to wake the patient
  6. 6
    Scalpel-bougie-tube cricothyrotomy

    1. Extend the neck; identify the cricothyroid membrane 2. Vertical skin incision over cricothyroid membrane (~8 cm long) 3. Horizontal stab through the membrane 4. Insert bougie caudally 5. Railroad 6.0 ETT over bougie 6. Inflate cuff, confirm with EtCO₂, secure > Avoid needle cricothyrotomy if surgical option available — jet ventilation has high complication rate (barotrauma).

  7. 7
    Post-event
    • Document airway exam, attempts, devices used, complications
    • Award patient a difficult airway letter for medical record
    • MedicAlert bracelet
    • Notify patient and family

Common Pitfalls

  • Delaying SGA placement after one or two failed intubation attempts.
  • Insisting on more laryngoscopy attempts in a desaturating patient.
  • Choosing needle cricothyrotomy over surgical when adult equipment is available.
  • Forgetting sugammadex when roc was used.

References & Further Reading

  1. 1
    GuidelineOpen source

    Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136(1):31-81.

  2. 2
    Journal

    Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK (NAP4). Br J Anaesth. 2011;106(5):617-642.

  3. 3
    WebOpen source

    Stanford Anesthesia Cognitive Aid Group. Stanford Anesthesia Emergency Manual. emergencymanual.stanford.edu.

  4. 4
    Textbook

    Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.

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