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Chapter: Essential Anesthesia From Science to Practice : Clinical management : Airway management

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Can’t intubate situations

Here the hearts (of the caregivers) begin to pound . . . when the vocal cords cannot be visualized.

Can’t intubate situations

Here the hearts (of the caregivers) begin to pound . . . when the vocal cords cannot be visualized. If this problem arises after adequate pre-oxygenation, you will have won valuable time before serious hypoxemia ensues. The first thing we try is to change the patient’s position, the laryngoscope blade, and/or the laryngoscopist. If this does not help (and the patient is still apneic), then another technique must be attempted (Table 2.3).


The selection of rescue technique depends on the situation, experience of the physician, availability of equipment, and whether mask–ventilation is possible. For example, “can’t intubate, can’t ventilate” scenarios necessitate rapid inter-vention, and thus, fiberoptic intubation would not be a likely choice for an inex-perienced physician; placement of an LMA is much more likely to be successful. Whereas in a “can’t intubate, can ventilate” scenario, we may be able to mask– ventilate the patient’s lungs while the surgeon does a tracheostomy or wait until the patient awakens and then perform an awake fiberoptic intubation. Remem-ber that non-depolarizing muscle relaxants cannot be reversed until the patient regains at least one twitch on the train-of-four (ulnar stimulation), which may require 30 minutes to more than an hour depending on the muscle relaxant and dose administered. For this reason, we choose short-acting drugs, e.g., succinyl-choline, when we anticipate difficulties: if intubation fails, the drug effect will wear off within a few minutes, and the patient can once again breathe spontaneously.


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