Section 1
The 60-Second Resuscitation Card (First 5 Minutes)
When face-mask ventilation, video laryngoscopy, and a 2nd-generation Supraglottic Airway (SGA) all fail to produce a square-wave ETCO₂ trace, the patient is in a Cannot Intubate, Cannot Oxygenate (CICO) emergency [1,2]. Every 60 seconds of hesitation on the vertical portion of the oxyhemoglobin dissociation curve increases hypoxic brain injury and cardiac arrest exponentially [1,3].
0:00
Immediate Bedside Action & Exact Maneuver / Dose
Declare CICO / Supraglottic Rescue Bridge: If ETT fails and SpO₂ < 90%, immediately insert a 2nd-Generation SGA (i-gel Size 4 for 50–90 kg; Size 5 for > 90 kg) [1,2]. If SGA fails to generate square-wave ETCO₂ and chest rise within 2 breaths, loudly declare “CICO — Emergency Front-of-Neck Airway!”
Ensure 100% neuromuscular blockade (give Rocuronium 1.2 mg/kg IV if not already fully paralyzed) [1].
Ensure 100% neuromuscular blockade (give Rocuronium 1.2 mg/kg IV if not already fully paralyzed) [1].
Equipment / Setup Specification
i-gel SGA with water-soluble lubricant + 12 Fr gastric decompression tube; open CICO Scalpel-Bougie Pack immediately.
Physiological & Mechanical Objective
2nd-generation SGA achieves higher pharyngeal seal pressure (30–35 cmH₂O) and isolates the esophagus; full paralysis eliminates laryngospasm and vocal cord resistance during cricothyrotomy [1].
0:30
Immediate Bedside Action & Exact Maneuver / Dose
Positioning, Oxygen Continuation & Laryngeal Handshake: Hyperextend the neck (place pillow/roll under shoulders unless unstable c-spine). Maintain 100% O₂ via upper airway (nasal cannula at 15 L/min or SGA). Stand on the patient’s left side (if right-handed) and perform the 3-Step Laryngeal Handshake to lock the cricothyroid membrane (CTM) between thumb and middle finger [1].
Equipment / Setup Specification
No. 10 Scalpel (broad rounded belly), 14–15 Fr Frova/Gum-Elastic Bougie (coudé tip), and 6.0 mm ID Cuffed ETT (pre-checked cuff with 10 mL syringe) [1].
Physiological & Mechanical Objective
Neck extension stretches the trachea superiorly out of the mediastinum, widening the longitudinal CTM height from 4 mm to 9–10 mm and stabilizing the larynx against lateral slippage [1,4].
1:30
Immediate Bedside Action & Exact Maneuver / Dose
Execute Scalpel-Finger-Bougie Cricothyrotomy:
• Palpable CTM: Make a single horizontal stab incision through skin and CTM (blade sharp edge toward operator) → rotate blade 90° caudally → slide bougie along blade into trachea [1].
• Impalpable CTM (Obesity/Edema/Hematoma): Make an 8–10 cm midline vertical skin incision (caudal-to-cephalad), blunt-dissect with both index fingers to palpate CTM directly, then incise CTM horizontally [1].
• Palpable CTM: Make a single horizontal stab incision through skin and CTM (blade sharp edge toward operator) → rotate blade 90° caudally → slide bougie along blade into trachea [1].
• Impalpable CTM (Obesity/Edema/Hematoma): Make an 8–10 cm midline vertical skin incision (caudal-to-cephalad), blunt-dissect with both index fingers to palpate CTM directly, then incise CTM horizontally [1].
Equipment / Setup Specification
Advance coudé bougie 10–15 cm caudally (feel tracheal ring clicks / carinal hold-up); railroad lubricated 6.0 mm cuffed ETT until cuff is 1 cm past CTM (5–6 cm skin mark), inflate cuff, confirm ETCO₂ [1].
Physiological & Mechanical Objective
Vertical midline skin incision stays strictly in the avascular linea alba colli (avoiding anterior jugular veins) and overcomes ultrasound/palpation blindness in obese or swollen necks [1,4].
3:00
Immediate Bedside Action & Exact Maneuver / Dose
Obstructed / Displaced Tracheostomy Algorithm (“Green vs. Red”): Apply O₂ to BOTH face AND stoma (unless total laryngectomy) [5]. Remove inner cannula and pass a 12–14 Fr suction catheter. If catheter will NOT pass: Deflate cuff. If still obstructed/cyanotic: Immediately remove the tracheostomy tube [5].
(Wait: If mature > 7 days, intubate stoma with 6.0 mm ETT over bougie; if fresh ≤ 7 days, intubate orally from above while occluding stoma) [5].
(Wait: If mature > 7 days, intubate stoma with 6.0 mm ETT over bougie; if fresh ≤ 7 days, intubate orally from above while occluding stoma) [5].
Equipment / Setup Specification
Tracheostomy emergency box: Spare inner cannula, 10 mL syringe (cuff deflation), suture cutter, tracheal dilator, 14 Fr suction catheter, flexible bronchoscope, 6.0 mm cuffed ETT.
Physiological & Mechanical Objective
Deflating the cuff allows airflow around a tube whose tip has herniated into a pre-tracheal false tract; removing a blocked tube eliminates lethal ball-valve tension mediastinal emphysema [5].
5:00
Immediate Bedside Action & Exact Maneuver / Dose
Tracheoinnominate Fistula (TIF) Massive Hemorrhage Salvage: If pulsating bright-red arterial blood erupts from a tracheostomy: (1) Hyperinflate tracheostomy cuff with 10–20 mL air (> 50 cmH₂O) [6]. (2) If bleeding persists: Intubate orally from above with a 7.0 mm cuffed ETT advanced distal to the stoma, withdraw tracheostomy tube, and execute the Utley Maneuver (insert index finger through stoma and compress the innominate artery anteriorly against the posterior manubrium) while rolling to the OR [6,7].
Equipment / Setup Specification
Activate Massive Transfusion Protocol (1:1:1 PRBC:FFP:Platelets); No. 10 scalpel to widen stoma for index finger insertion; immediate Cardiothoracic/Vascular Surgery median sternotomy [6,7].
Physiological & Mechanical Objective
Direct digital compression tamponades the high-pressure brachiocephalic trunk against the rigid bony posterior sternum, maintaining cerebral and pulmonary isolation until surgical ligation [6,7].
| Time | Immediate Bedside Action & Exact Maneuver / Dose | Equipment / Setup Specification | Physiological & Mechanical Objective |
|---|---|---|---|
| 0:00 | Declare CICO / Supraglottic Rescue Bridge: If ETT fails and SpO₂ < 90%, immediately insert a 2nd-Generation SGA (i-gel Size 4 for 50–90 kg; Size 5 for > 90 kg) [1,2]. If SGA fails to generate square-wave ETCO₂ and chest rise within 2 breaths, loudly declare “CICO — Emergency Front-of-Neck Airway!” Ensure 100% neuromuscular blockade (give Rocuronium 1.2 mg/kg IV if not already fully paralyzed) [1]. | i-gel SGA with water-soluble lubricant + 12 Fr gastric decompression tube; open CICO Scalpel-Bougie Pack immediately. | 2nd-generation SGA achieves higher pharyngeal seal pressure (30–35 cmH₂O) and isolates the esophagus; full paralysis eliminates laryngospasm and vocal cord resistance during cricothyrotomy [1]. |
| 0:30 | Positioning, Oxygen Continuation & Laryngeal Handshake: Hyperextend the neck (place pillow/roll under shoulders unless unstable c-spine). Maintain 100% O₂ via upper airway (nasal cannula at 15 L/min or SGA). Stand on the patient’s left side (if right-handed) and perform the 3-Step Laryngeal Handshake to lock the cricothyroid membrane (CTM) between thumb and middle finger [1]. | No. 10 Scalpel (broad rounded belly), 14–15 Fr Frova/Gum-Elastic Bougie (coudé tip), and 6.0 mm ID Cuffed ETT (pre-checked cuff with 10 mL syringe) [1]. | Neck extension stretches the trachea superiorly out of the mediastinum, widening the longitudinal CTM height from 4 mm to 9–10 mm and stabilizing the larynx against lateral slippage [1,4]. |
| 1:30 | Execute Scalpel-Finger-Bougie Cricothyrotomy: • Palpable CTM: Make a single horizontal stab incision through skin and CTM (blade sharp edge toward operator) → rotate blade 90° caudally → slide bougie along blade into trachea [1]. • Impalpable CTM (Obesity/Edema/Hematoma): Make an 8–10 cm midline vertical skin incision (caudal-to-cephalad), blunt-dissect with both index fingers to palpate CTM directly, then incise CTM horizontally [1]. | Advance coudé bougie 10–15 cm caudally (feel tracheal ring clicks / carinal hold-up); railroad lubricated 6.0 mm cuffed ETT until cuff is 1 cm past CTM (5–6 cm skin mark), inflate cuff, confirm ETCO₂ [1]. | Vertical midline skin incision stays strictly in the avascular linea alba colli (avoiding anterior jugular veins) and overcomes ultrasound/palpation blindness in obese or swollen necks [1,4]. |
| 3:00 | Obstructed / Displaced Tracheostomy Algorithm (“Green vs. Red”): Apply O₂ to BOTH face AND stoma (unless total laryngectomy) [5]. Remove inner cannula and pass a 12–14 Fr suction catheter. If catheter will NOT pass: Deflate cuff. If still obstructed/cyanotic: Immediately remove the tracheostomy tube [5]. (Wait: If mature > 7 days, intubate stoma with 6.0 mm ETT over bougie; if fresh ≤ 7 days, intubate orally from above while occluding stoma) [5]. | Tracheostomy emergency box: Spare inner cannula, 10 mL syringe (cuff deflation), suture cutter, tracheal dilator, 14 Fr suction catheter, flexible bronchoscope, 6.0 mm cuffed ETT. | Deflating the cuff allows airflow around a tube whose tip has herniated into a pre-tracheal false tract; removing a blocked tube eliminates lethal ball-valve tension mediastinal emphysema [5]. |
| 5:00 | Tracheoinnominate Fistula (TIF) Massive Hemorrhage Salvage: If pulsating bright-red arterial blood erupts from a tracheostomy: (1) Hyperinflate tracheostomy cuff with 10–20 mL air (> 50 cmH₂O) [6]. (2) If bleeding persists: Intubate orally from above with a 7.0 mm cuffed ETT advanced distal to the stoma, withdraw tracheostomy tube, and execute the Utley Maneuver (insert index finger through stoma and compress the innominate artery anteriorly against the posterior manubrium) while rolling to the OR [6,7]. | Activate Massive Transfusion Protocol (1:1:1 PRBC:FFP:Platelets); No. 10 scalpel to widen stoma for index finger insertion; immediate Cardiothoracic/Vascular Surgery median sternotomy [6,7]. | Direct digital compression tamponades the high-pressure brachiocephalic trunk against the rigid bony posterior sternum, maintaining cerebral and pulmonary isolation until surgical ligation [6,7]. |
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