Cite this post as:
Scott Weingart, MD FCCM. Shock Trauma Center (STC) Failed Airway Algorithm. EMCrit Blog. Published on January 26, 2013. Accessed on February 14th 2025. Available at [https://emcrit.org/emcrit/shock-trauma-center-failed-airway-algorithm/ ].
Financial Disclosures:
The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.
CME Review
Original Release: January 26, 2013
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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Looks pretty similar to the difficult airway society algorithm although obviously waking them up and doing it another day isn’t an option in the ED!
http://www.das.uk.com/files/ddl-Jul04-A4.pdf
When you actually break it down to core concepts, absolutely; but the actual algorithm is needlessly complex IMHO. Ref: ASA Difficult Airway Algorithm 2013
Completely agreed. I think it’s ludicrous when emergency algorithms take more then half a second to read.
Am I reading this wrong or does the ASA guideline actually read “Can’t Bag mask –> Can’t make an LMA work –> Can’t ventilate, Can’t intubate –> Call for help and go back to BVM/LMA which from earlier attempts did not work only to somehow possibly end up successfully ventilating the patient?? To me that just sounds fundamentally wrong unless my neurons aren’t synapsing again…..
That’s what it looked like to me as well.
Algorithims are really only good for planning, not so good for doing.
THE STC one is simple enough to be actually used during a procedure..not that I recommend that but its simple enough to memorise and apply.
You could have the resus room lifeguard reading the STC algo and acting as a safety guide
I partic like the emphasis in the STC algo on using ETCO2 waveform monitoring to assess efficacy of BVM or SGA ventilation. Serves dual purpose..good way to heck ventilatory performance but also useful check of working capnography, before intubation!
If the lifeguard’s sole role was to say after the third intubation, “There will be no more attempts at intubation via DL/VL!”, they would have done their job well.
I like the “lifeguard” idea. That’s the same way we advocate the Vortex cognitive tool being utilised.
This algorithm is reassuringly virtually identical to the one I developed back in my heady junior registrar days at my old shop in Perth, WA in the early noughties. The thing I’d add is to CHANGE SOMETHING between laryngoscopy attempts – position, bougie, operator, ELM…any or all…but something. No point in just hammering away doing the same thing! I also had a prominent “call for help” red arrow off to the side right at the start
Yep, agree on both counts
Nice post. We are teaching the same difficult airway management algorithm to all traniees (and consultants). The algorithm is far less in use after we routinely paralyse at the same time as we push the sedative. I would like to stress the concept ” if you have an airway- don’t spoil it”. In my experience ( anaesthesia) a sub-optimal BVM airway/ LMA is far more common than a real cannot ventilate-cannot intubate situation. In these cases there is seldom an appropriate etco2 wave. Don’t spoil a sub-optimal (but working) airway by multiple attempts- call for the best intubator available and… Read more »
Andreas, I see where you are coming from. This algo is intended for the intubation of the critically ill patient. The best intubator available should be doing the airway from the get go. While the ETCO2 waveform may not be appropriate as if it was an ETT, there should be a ET demonstration of gas exchange or else you are probably not exchanging gas.
Andreas, I agree with you completely. The reality is that whilst everyone involved in airway management should have achieved an appropriate level of airway expertise, there is a variation in the degree expertise beyond this. I would agree with Scott that if you forsee a difficulty and you know someone has particularly advanced airway skills you should get them in from the start. The difficulty is that many difficult intubations aren’t anticipated as such and it may not be realistic to have the most skilled intubator in the hospital standing at the head of the bed for every intubation. If… Read more »
I agree with Scott. ETCO2 waveform demonstrates gas exchange and more importantly a sufficiently patent airway to allow such. It is a difficult transition but we need to accept the reliability of the ETCO2 in monitoring airway patency and adequacy. It is not good enough to just look for chest wall rise anymore. Many times you can be ventilating fine with good gas exchange and ETCO2 and in these big chested patients you see almost no chest wall movement! The situation is different of course if you are insufflating oxygen where your primary goal is not gas exchange but oxygen… Read more »
Well I agree with you both. My comments were based on the reference from Shock Trauma above. As far as I can see the context in that paper is in-hospital. I totally agree with Minh that prehospital ET is a different issue. No help is usually available, so no need to put “shout for help” in the algorithm. As Minh point out, a drilled team might be the substitute. I would still argue that in a “cannot ventilate, cannot intubate” situation, my biggest concern would be hypoxia, and not hypercarbia. As such, if I can manage to oxygenate the patient,… Read more »
Andreas, I believe we are not on the same page on the purpose of ETCO2. It has nothing to do with hypercarbia. It is a guarantee of gas exchange. It is an oxygenation issue, not a carbon dioxide issue.
Emcrit, I’m sorry. I guess the my effort to discuss the topic using a foreign language went slightly the wrong direction…. What I probably ment to say was: no doubt an et co2 wave gives a reliable indication of gas exchange. My point was: ( trying to formulate correctly this time) getting an etco2 wave during airway management can sometime be difficult, especially during BVM ventilation (which is the most serious problem in a cannot ventilate cannot intubate situation). If absent etco2 wave is the only measure of cannot ventilate, especially junior docs will have to enter the difficult airway… Read more »
This has not been my experience. If a BVM breath goes in, when the patient expires there will be ETCO2 waveform. There is no where else for the breath to go even if there is a slight leak around the mask. This is what the BVM PEEP valve is predicated on as well. If you are not seeing a wave, you are not oxygenating or ventilating.
I have a paper under peer review now where we demonstrated the feasibility of ETCO2 waeform capnography using a face mask and main stream sensor. I have been doing this to monitor my ketamine retrieval sedation for 5 years now. It indicates adequate airway patency and gas exchange in a noisy environment where you typically cannot observe chest wall movement during certain phases of transport. I fail to see why it would not be an even better monitor of adequate BVM face mask ventilation. This is a simple brilliant idea. The true power of FOAMEd that continues to deliver for… Read more »
As to ETCO2 for BVM adequacy, love to say it was mine, but the first day I walked into fellowship, the anesthesiologists were doing it in the trauma bay and I smacked myself in the head. Makes a ton of sense.
We always blow to know before using ETCO2 in a real pt, so we are sure the equipment is not the issue.
I agree with having ETCO2 in place during preoxygenation and it highlights why there needs to be more common training programs across multiple critical care disciplines to allow this exchange of ideas (as this is routine practice in anaesthesiology but not yet in other crit care settings). It does a few things: 1. It makes you check that the ETCO2 monitor is working 2. It gives you an indication of the adequacy of the seal with the face mask prior to giving any induction drugs (i.e. if you can’t get a good enough seal to get an ETCO2 trace during… Read more »
I mean “unfasted” patients obviously
Some good points here. I would like to add that having an etco2 wave during preox probably indicates an optimal EtO2 ( if no EtO2 is available). During OR inductions ( especially in pts with low FRC; pregnant, ileus, neonates) I always aim for an EtCo2 wave which is a prereq for max EtO2. It is a free and very important safety manouvre before risky inductions. Some may feel that keeping the mask thight enough to get an appropriate EtCo2 wave means discomfort for the patient, but in my eyes it is simply a question of communication and adjusting the… Read more »
At least with the current generation of monitors, it doesn’t happen. If the patient has a pulse, there will be ETCO2. If the patient doesn’t have a pulse, but they are getting CPR you will have a waveform. The ETCO2 value may be quite low, but there will be a waveform with gas exchange. The references for this are elsewhere on the blog for the purpose of assessing intubation during cardiac arrest.
Anytime I approach a potentially dodgy airway, I take myself down your algorithm right from the get-go. That is, I thread a bougie and act like an “attending” — optimizing everything and verbalizing what i might need — “BURP” maneuver, patient positioning, inline stabilization, etc. Your first shot is still your best shot. If you think you might need a bougie, you probably need a bougie, and it isn’t going to hurt anything.
Couldn’t agree more. My first intubation attempt is always done with a bougie in trauma patients.
Why isn’t the glidescope part of the algorithm?
I am a critical care nurse at a large urban hospital. Ever since I listened to the podcasts on difficult airways this algorithm always comes to mind when we are intubating a patient. This morning at the end of my shift we had an unfortunate situation where a patients respiratory status was failing to improve on bipap and the decision was made to intubate. The patient was very obese and you could see that her airway was going to be a problem. The nurse anesthetist arrived. Several staff members raised concerns about the patients airway prior to starting and suggested… Read more »
Thanks for sharing this story, Lexi
I love the simple check list or algorhythm, I know in high stress situations my IQ drops significantly especally when I am emersed in providing care. In a prehospital or interfacility transport of critical patients ETCo2 set up and attached from the very beginning also saves hands and space, and I could not agree more with Minh that to hear or see in the dark noisy and vibrating cabin, where most of the ambiant noise is in the same range as the noises you are trying to hear is not a reality. A value and a wave form that you… Read more »