ISIS CURRICULUM

Team Training:
Unanticipated
Difficult
Airway
Created: July 1, 2006
Modified: August 19, 20198
 CURRICULUM OUTLINE

1 Contact Information

2 Description of Curriculum

3 Target Trainees

4 Prerequisite Knowledge and Skills

5 Goals and Objectives

6 Instructor Notes

7 Common Errors & Prevention

Strategies

8 Cognitive Training

9 Skill Training

10 Equipment Setup
00
11 Assessment Methods
1
12 Appendices
1
Team Training: Unanticipated Difficult Airway 2
 1. Contact Information

Stefan Lombaard, MD
Assistant Professor
Department of Anesthesiology
Box 356540, School of Medicine
University of Washington
1959 NE Pacific Street
Seattle, WA 98195
Email: lombaard@u.washington.edu
Pager: 206-559-1673

Brian K. Ross, PhD, MD

Professor
Department of Anesthesiology
Box 356540, School of Medicine
University of Washington
1959 NE Pacific Street
Seattle, WA 98195
Email: bkross@u.washington.edu
Pager: 206-998-1060

Julia Metzner, MD
Assistant Professor
Department of Anesthesiology
Box 356540, School of Medicine
University of Washington
1959 NE Pacific Street
Seattle, WA 98195
Email: metznj@u.washington.edu
Pager: 206-541-4938

Megan Sherman
Program Coordinator
Institute for Surgical and Interventional Simulation
Box 356410, School of Medicine
University of Washington
1959 NE Pacific Street
Seattle, WA 98195
Email: shermm@u.washington.edu
Phone: 206-598-7779

Sara Kim, PhD

Associate Director, Education and Curriculum
Institute for Surgical and Interventional Simulation
Box 357240, School of Medicine
1959 NE Pacific Street
Seattle, WA 98195
Email: sarakim@u.washington.edu
Phone: 206-616-0597

Team Training: Unanticipated Difficult Airway 3

 2. Description of Curriculum

Course Overview:

This course is designed to teach learner(s) to recognize and manage an airway

emergency which occurs in the setting of a failed spinal anesthetic.

The patient experiences pain after the surgery has started due to the tourniquet
and, as result of injudicious sedation, becomes apnoeic and starts to
desaturate. The patient simulator is placed in a state where it is impossible to be
ventilated or intubated. The resident should recognize the seriousness of the
situation and call for help. The ‘attending anesthesiologist’ should proceed
according to American Society of Anesthesiologists (ASA) unanticipated difficult
intubation guidelines, and eventually perform a cricothyroidotomy.

The secondary goal will be for the more junior resident (R2) to be able to
perform intrathecal anesthesia. This includes reviewing the patient history and
physical examination, especially an airway examination and discussing informed
consent regarding the potential benefits and risks of a spinal anesthetic
including the potential for a failed regional which may require general
anesthesia. They should also be able to set up and perform the procedure using
the appropriate monitoring.

Educational Rationale on How the Course Generalizes to Real-

Life Circumstances:
A “cannot intubate and cannot ventilate” event is a rare but serious situation
which can arise due to the administration of anesthetic drugs. An
anesthesiologist should be able to do a thorough preoperative airway
examination in order to assess the likelihood of both difficult ventilation & difficult
intubation. If the situation does arise unexpectedly however, the learner should
be able to deal with it appropriately.

The goal of this course is to provide the learner with an opportunity to manage a
life threatening airway emergency which plays out in real time, where the correct
steps need to be taken in a limited period of time. Key elements include: 1)
evaluating the preoperative airway, even though the procedure is performed
under a regional anesthetic (note that the difficult airway will be unrecognized),
2) recognizing the need to call for assistance early in an event, 3) being able to
use various alternative techniques for airway management, and 4) optimizing
resource management skills.

Duration of Training Session: 2 hours.

Frequency of Course: 6 to 10 times per year.
Number of Trainees per Session: 3-5
Team Training: Unanticipated Difficult Airway 4
 3. Target Trainees

Primary: Anesthesia Junior and Senior

Residents

Secondary: N/A

Team Training: Unanticipated Difficult Airway 5

 4. Prerequisite Knowledge and Skills

 Required background knowledge:

 Anatomy related to placing spinal anesthesia
 Drugs used for spinal anesthesia
 Indications and contraindications for rapid sequence
induction
 Drugs used for rapid sequence induction
 ASA Difficult airway algorithm
 ASA Guidelines for basic monitoring

 Required background skills expected in trainees prior to

receiving training in the target course:
 Ability to do spinal anesthesia
 Airway assessment
 Rapid sequence induction
 Emergency airway management
 Bag mask ventilation: ensure proper
technique
 Proper use of oral & nasal airway
 Placing LMA
 Performing laryngoscopy
 Performing cricothyroidotomy

Team Training: Unanticipated Difficult Airway 6

 5. Goals and Objectives
Goal 1: Proficiency in Intrathecal Anesthesia
The learner will gain proficiency in performing intrathecal anesthesia in a safe
and professional manner. (ACGME Competencies: Medical Knowledge 1,
Patient Care2, Interpersonal and Communication Skills 3, Professionalism4,
System-based Practice5, Practice-based Learning6)

Objective 1a- Patient Assessment prior to surgery [1,2,3,4]

The learner will be expected to identify 3-5 key features that he/she
would look for in a preoperative history & physical examination of a
patient presenting for semi-urgent surgery. (For example: associated injuries,
cardio respiratory disease, airway examination, identify risk factors for aspiration,
previous anesthetic history, current medications, allergies)

Objective 1b - Informed consent [2,3,4]

The learner will list relevant risks & benefits of doing spinal anesthesia.

Objective 1c– Appropriate monitoring [1,2]

The learner should be able to describe the ASA standards for basic
anesthetic monitoring requirements.

Objective 1d- Equipment setup [2]

The learner should be able to set up the equipment required to perform
an intrathecal block observing aseptic technique. He/she should be able
to prepare the appropriate drugs in the appropriate amount which will be
used. He /she is expected to demonstrate knowledge regarding the
choice of spinal needle appropriate for each situation.
[1]
Objective 1e-Demonstrate understanding of the relevant anatomy
The learner should be able to delineate the landmarks for spinal
anesthesia. It should be placed at L3/4 or lower.

Objective 1f-Technical skills [2]

The learner will demonstrate competence in the technique of placing a
spinal anesthetic including the use of specific spinal needle. He/she
should be able to place the spinal needle in a controlled way and identify
the intrathecal space before injecting the anesthetic drugs.

Team Training: Unanticipated Difficult Airway 7

 5. Goals and Objectives
Goal 2: Management of conscious sedation
The learner will be able to provide sedation in a safe and professional manner.
(ACGME Competencies: Medical Knowledge 1, Patient Care2, Interpersonal
and Communication Skills3, Professionalism4, System-based Practice5)

Objective 2a- Appropriate sedation [1,2,3,4,5]

The learner will be expected to provide sedation with continuous
assessment of the effects of the sedative medications on the level of
consciousness and on cardiac and respiratory function.
They should be prepared to convert to general anesthesia if required.

Objective 2b- Recognition of over sedation [1,2,3,4,5]

The learner should anticipate that using more sedatives and intravenous
analgesia could result in progressing beyond “conscious sedation”. The
patient’s level of consciousness and respiratory rate should be
continually re-assessed. They should recognize when the patient
becomes unresponsive to voice and eventually physical stimulation.
Airway support should be started when the patient becomes apneic.

Team Training: Unanticipated Difficult Airway 8

 5. Goals and Objectives
Goal 3: Dealing with an perioperative airway emergency
The learner will become proficient in dealing with an emergency situation, which
plays out in real time where the patient is rapidly desaturating and cannot be
ventilated or intubated due to upper airway obstruction. (ACGME
Competencies: Medical Knowledge 1, Patient Care2, Interpersonal and
Communication Skills3, Professionalism4, System-based Practice5,
Practice-based Learning6)

Objective 3a - Airway assessment [1,2,5]

The learner will identify potential risks for a difficult ventilation and
intubation.

Objective 3b – Recognize problem & call for help [3,5,6]

The learner should recognize the seriousness of the situation and call for
help early.

Objective 3c – Go through the appropriate steps of the ASA difficult

airway algorithm [1,5,6]
The learner should become skilled at different methods of attempting to
provide ventilation. They should be able to list alternative options when a
given technique fails.

Objective 3d – Cricothyroidotomy
The learner should be able to demonstrate competency in performing a
cricothyroidotomy in an emergency situation.

Goal 4: Familiarity with equipment available to manage an

unanticipated difficult airway (Competencies: Medical Knowledge1,
Patient Care2, Interpersonal and Communication Skills 3, Professionalism4,
System-based Practice5, Practice=based-Learning 6)

Objective 4a - Bag mask ventilation[1,2]

The learner should attempt bag mask ventilation with one hand then use
a two handed technique while asking an assistant to do the ventilation.

Objective 4b - Supraglottic airway devices[1,2]

The learner should be able to place oral or nasopharyngeal airway
devices to facilitate bag mask ventilation.

Objective 4b - Laryngoscopy
The learner should be able to use a laryngoscope and additional devices
such as a stylette, appropriately.

Team Training: Unanticipated Difficult Airway 9

 5. Goals and Objectives

Goal 5: Extubation
After stabilizing the patient with a surgical airway, the learner should present a
plan for further management of the patient. The learner should be able to
discuss what they would do postoperatively when the patient is ready to be
extubated. (ACGME Competencies: Medical Knowledge 1, Patient Care2,
Interpersonal and Communication Skills 3, System-based Practice5,
Practice-based Learning6)

Objective 5a – Criteria for extubation [1,5]

The learner will describe the process of assessment to ensure a
successful extubation.

Objective 5b – Management of the extubation [1,2,3]

The learner should explain how he/she would safely extubate the patient
including steps that would facilitate re-intubation if the patient is not able
to maintain an airway or adequate ventilation.

Goal 6: Team Training and Communication Skills

The learner will become skilled in leadership and the management of operating
personnel including nurses and anesthesia technicians. (Competencies:
Interpersonal and Communication Skills 3, Professionalism4, System-based
Practice5, Practice-based Learning6)

Objective 6a – Team Training and Communication Skills

Given a full-scale high-fidelity simulation using a human patient simulator
in which the learners are faced with an inability to maintain or secure an
airway, the learner will direct available resources to manage the crisis
situation prioritizing patient safety.

Goal 7: Record Keeping

The learner should be able to demonstrate the importance of accurate recording
keeping during an intra-operative critical event (Competencies: Patient Care2,
Professionalism4, System-based Practice5)

Objective 7a– Record Keeping

Given a full-scale high-fidelity simulation using a human patient simulator
in which they have to deal with an airway emergency, the learner should
be able to accurately document records during the event.

Team Training: Unanticipated Difficult Airway 10

 6. Instructor’s Notes
1. Ensure simulation room is correctly prepared
 Ensure the room is set up exactly the same as the hospital setting that
the learners are used to. All routinely used equipment should be in an
expected location.
 Additional items, such as the code cart or difficult airway cart, should not
be visible. If needed, the participants should specifically request these
items.
 Standard monitoring may be attached prior to the simulation session in
order to save time. With junior residents, monitoring may be left
unconnected to ensure proper knowledge of appropriate monitoring
required for spinal anesthesia.

2. Briefing prior to simulation session

 Discuss capabilities of simulator: where pulses can be felt, where to
listen for breath sounds.
 The instructor should ensure that learners can use the monitoring
correctly (For instance, the learner should be able to start the automatic
blood pressure cuff and set it to repeat the blood pressure measurement
at the appropriate interval).
 The instructor should discuss resources available (i.e. asking
anesthesia technician for equipment, location of telephone to call for
help, etc.).
 The instructor should discuss any deviations from the situation they
would expect in the operating room. For instance: the inhalation agent
vaporizer does not have an anesthetic agent present. What is set on the
vaporizer dial will reflect the depth of anesthesia.
 The learner should not assume that there is a problem with the
simulator if something unexpected happens. They should act as they
would if this were a real patient. Everything happens in real time (i.e. a
chest X-ray will not be available, instantaneously).
 The instructor will establish a safe environment. Emphasizing the focus
of the course is to improve their ability to deal with a crisis situation.
 Discuss principles of team management, including what is expected of
the team leader and team members.
 Instruct learners to call out drug names and dosages, so that this can be
entered in the simulation.
 Trainees should sign a consent form, agreeing not to discuss
performance of team members outside of the simulation environment.
 We also mention that the session is recorded on video as an aid during
the debriefing. We ask them to sign a consent for archiving the video. If
any one of the participants is not agreeable for the video to be archived,
it is destroyed at the end of the day.

Team Training: Unanticipated Difficult Airway 11

 6. Instructor’s Notes Cont’d
3. Additional notes during session
 The “patient” should insist on having a spinal, citing a friend (no familial
relationship) has had complications related to general anesthesia.
 The spinal simulator is brought into the room when the learners are
ready to proceed with a spinal. The simulator should be in clear view of
the video camera used to record the session.
 We have found that some learners will persist in doing oral intubation to
the extent of breaking teeth on the manikin. We have changed to using
rubber teeth. The “surgeon” should watch for persistent attempts at
intubation, and point out how repeated intubation attempts may
traumatize the airway, making subsequent attempts more difficult.
 The “patient” should respond to actions by the anesthetic team (i.e.
“The mask makes me feel claustrophobic” when a mask is placed on his
face, or “Ouch!” when the spinal is done). This will add to the realism of
the scenario and consequently, the degree of engagement by learners.
 When the learners call for a surgical airway, we bring in a
cricothyroidotomy simulator. Once the surgical airway has been
established, the vital signs improve and the simulation is stopped.

4. Debriefing
 Please refer to section B for detailed debriefing notes.
 Participants are accompanied to the debriefing room. A video recording
is available to review key parts of the simulation.
 Key points for the debriefing:
 Facilitate the discussion rather than giving a lecture,
 Learners should discuss why they chose certain courses of action
and discuss the consequences. Ask what they would do the same or
differently if they did the same scenario again,
 Engage everyone in the discussion particularly quiet team members.
 Key topics for discussion should include:
 Sedation in a patient with a full stomach,
 Spinal anesthesia,
 Doing a rapid sequence induction,
 Management of a "Cannot intubate, cannot ventilate" emergency.
 Briefly review the ASA guidelines for managing a difficult airway. Every
participant receives a copy of the current guidelines.

Team Training: Unanticipated Difficult Airway 12

 7. Common Errors & Prevention Strategies
Common errors observed in trainees and strategies for helping
address the errors include:

1. Failure to anticipate a potential full stomach.

Review factors which can delay gastric emptying (i.e., pain drugs)
Discuss the potentially catastrophic consequences of dealing with a
difficult airway in the setting of aspiration.

2. Persistence of sedation when the regional is not adequate.

Review the potential risks for apnea, airway obstruction & aspiration,
when sedation is used to cover pain from surgery or the tourniquet,
in a situation where the spinal anesthesia is clearly not adequate.

3. Fixation error: failure to advance to a different approach if one

method of ventilation is not effective.
The instructor will discuss the potential for causing trauma, as well
as the consequences of delaying definitive management of hypoxia.
Learners should be able to explain reasons why a particular
technique was not successful, and then try a different approach,
circumventing the problem.

4. Failure to call for help early

The instructor should emphasize the importance of calling for help
before the problem becomes life threatening.

5. Inefficient communication & teamwork

a. Lack of leadership
b. Unclear or ambiguous messages
The instructor should discuss the importance of clear
communication and leadership during the management of an
emergent airway management scenario.
General strategies to solve the problems
 Increase knowledge base through assigned reading and lectures.
 Keep debriefing focused to re-evaluate critical thinking and structure
planning of actions.
 Utilize areas for improvement as teaching points.
 Promote regular simulation training as an opportunity to correct
previous mistakes.

Team Training: Unanticipated Difficult Airway 13

 8. Cognitive Training

 Key methods for delivering cognitive training include the following:

 ASA Practice Guidelines for Management of the Difficult Airway

(This can be accessed via:
http://ww.asahq.org/publicationsAndServices/Difficult%20Airway.pdf

 Instructor led overview of managing a difficult airway during the

debriefing. (See Appendix B)

Team Training: Unanticipated Difficult Airway 14

 9. Skill Training
Participants:

Doctor #1: Attending anesthesiologist

(this is usually the most senior resident – R4)
Doctor #2: Anesthesia Resident (Junior resident)
Doctor #3: Available attending (This is generally the R3 resident)

Doctor #4 / Nurse #1: Circulating nurse

Instructor 1: Attending anesthesiologist
Instructor 2: Surgeon

Briefings:

1. The course will include a brief introduction to the simulator. Learners are asked to
not disclose the details of the scenario to other residents, and also to refrain from
discussing each other’s performance outside of the simulation environment.

2. Review capabilities of simulator:

 Breath sounds - where to listen, make them listen
 Heart sounds
 Blood pressure - can take manual BP, how to start NIBP
 Pulse - where to feel
 Voice
 Emphasize that when a drug is administered, the person giving it should
clearly state the name & dose of the drug.
 Do not assume that something is wrong with the simulator if a problem occurs.

3. Review equipment in room:

 Set the scene – the patient has been pre-assessed and is in the operating
room.
 Emphasize everything that occurs is actually happening.
 Address any questions?

4. Doctor #2 will be asked to wait in the lounge.

6. The patient should be anxious and complain about pain as the learners enter the
room. The patient should request more sedation.

7. The surgeon should prep & drape the field after the spinal block is established,
and then proceed with mock surgery. He or she will be unable to perform surgical
airway if requested but may be of assistance for any other tasks.

Team Training: Unanticipated Difficult Airway 15

 9. Skill Training-Continued

The Case:

Act #1: Simulation room: Handover

Instructor #1 will be the attending anesthesiologist originally assigned to

anesthetize the patient. He/she has already pre-assessed the patient and
has discussed performing a spinal anesthetic with the patient.

Instructor #1 will hand over care of the patient to all participants, except
Doctor #2. Doctor #1 (“Attending”) & Doctor 2 (“Resident”) will need to
introduce themselves to the patient and confirm the pre-assessment by
completing a focused history & examination including airway assessment.
The two will need to discuss how they would go about performing spinal
anesthesia including IV access, monitoring equipment, emergency drugs &
emergency equipment, etc.

Act #2: Simulation room: Spinal

Rhythm: sinus
HR: 83 bpm
BP: 150/90
Sat: 96%
RR: 20/min

This will be done using the spinal simulator. The learner should describe the
steps he/she will complete, as if this were a real patient. He/she should set
up a spinal tray and then perform a spinal. The learner should be able to
describe pertinent anatomy.
(If the residents are junior, the instructor would go through the correct
procedure for setting up the tray.)

The trainee will identify:

 What drugs
 Combinations of drugs
 Dosage

Team Training: Unanticipated Difficult Airway 16

 9. Skill Training-Continued
Act #3: Sedation

Rhythm: sinus O2 Sat 98%

HR: 60 bpm RR 18/min
BP: 110/60ETCO2 21mmHg (Connected to O2 mask)

IV line in situ
ECG, Pulse oximeter & NIBP in situ
O2 Mask on face with ETCO2 sample line attached

The “Patient”

Awake, anxious, requesting sedation (Is this going to hurt, what is

happening, what are you giving me etc.)

Block level is to T12, unable to move legs.

The surgeon places a tourniquet, preps & drapes field & (eventually) starts
operating.

After a period the patient starts complaining of pain in his leg related to the
tourniquet and requests more sedation until he becomes unresponsive and
apnoeic.

The events should be the same if the resident does a rapid sequence
intubation.

Trigger for Act 4 is sedation / rapid sequence induction

Arbitrary cutoff: midazolam > 5mg, fentanyl > 200mcg, propofol > 100mg or
propofol infusion

Team Training: Unanticipated Difficult Airway 17

 9. Skill Training-Continued

START TIMER

Act #4: Time 0-4 minutes: Can’t intubate / can’t ventilate

Rhythm sinus
HR 80  ramp up to 120 bpm
BP 150/95 ramp up to 170/100
O2 Sat 95%  ramp to 90% over 3 min
then down to 80% over 1 min
RR apnea
ETCO2 0 mmHg

Airway Inflate tongue & larynx

If the resident calls for help  bring in Doctor #3.

If requested: the surgeon is unable to do a tracheotomy.

The difficult airway cart is available on request.

Attempts to manually ventilate & intubate should be unsuccessful.

When a cricothyroidotomy is in place and the patient is being ventilated,

proceed to Act #8

Act #5: Time 4-6 minutes: Deteriorating oxygenation

Rhythm sinus
HR 120 bpm  ramp down to 30bpm + ventricular ectopic
beats
BP 170/100  ramp down to 64/35
O2 Sat 90%  ramp down to 60%
RR apnea
ETCO2 0 mmHg

Team Training: Unanticipated Difficult Airway 18

 9. Skill Training-Continued

Act #6: Time6+ minutes: Catastrophic deterioration

Rhythm sinus with runs of VT

HR 30 bpm
BP 64/35
O2 Sat 60%
RR 0/min
ETCO2 0 mmHg

Act #7: Cricothyroidotomy

Rhythm sinus
HR ramp to 90 bpm
BP ramp to 140/95
O2 Sat ramp up to 95% over 3 minutes
RR 15/min
ETCO2 70 mmHg

Act #8: Further management questions

Would you continue the case?

How would you manage extubation?

Team Training: Unanticipated Difficult Airway 19

 10. Equipment Setup

Room Set-Up:

The simulation room is prepared to simulate a real operating room

environment, which has been prepared by an anesthesia technician:

 SimMan on OR table, awake & breathing spontaneously

 Anesthesia machine at head end of bed and turned on
 Anesthesia circuit connected with mask
 Anesthesia cart with airway equipment, drugs and patient history &
physical
Standard monitoring connected: ECG, Pulse oximeter & blood pressure
cuff
 IV line in situ

Equipment:
 Spinal Simulator
 Spinal tray with drugs
 Surgery equipment incl. drapes, tourniquet
 Patient History and Physical Sheet on Clip Board
 Anesthesia Machine
 Code cart (hidden or outside OR)
 Difficult Airway Kit (hidden or outside OR)

Please refer to Appendix D for detailed list of items required.

Team Training: Unanticipated Difficult Airway 20

 11. Assessment Methods
Type(s) of Assessment Methods Used in This Course

 Pre-test Only 
 Team Evaluation

Pre-test + Post-test  Team Debriefing Evaluation

Post-test Only  Instructor Evaluation Form

 Performance Checklist  Simulation Experience

Evaluation Form

Team Training: Unanticipated Difficult Airway 21

 12. Appendices

Appendix A Admissions History and Physical

Appendix B Debriefing questions

Appendix C Suggested clinical questions

Appendix D Equipment set-up

Appendix E Performance checklist

Appendix F Team evaluation form
Appendix G Simulation evaluation form

Appendix H Content and Instructor evaluation form

Appendix I References
Appendix J Scenario flowchart

Team Training: Unanticipated Difficult Airway 22

 Appendix A: Admission History and
Physical
History:
55yr old male. Slipped & fell on his way to work. He has a fractured R ankle requiring
open reduction & internal fixation. He has had 10mg of IV morphine in the ER for
analgesia. They have also applied a temporary splint.
Last meal 07:00, Accident happened @ 09:00

PMH:
DM – diet controlled
Hypertension (controlled on Rx)
High cholesterol
Anxiety
Occasional reflux after meals

Medications:
Clonazepam 0.5mg nocte
Felodipine
Ranitidine 150mg bd

Social:
Occasional alcohol
Ex smoker. 30 pack year history.

No allergies.

No prior surgery. No family history of anesthesia related complications. However a

close friend has died under general anesthesia.

Examination:

VITAL SIGNS: Pulse 90 bpm, BP 155/95, oxygen saturation 96% on room air. He
weighs 94 kg and is 175cm tall.

GENERAL: He is a fit looking male, uncomfortable from pain in his leg, but otherwise in
no distress.

CARDIOVASCULAR: S1, S2 regular with no murmur.

LUNGS: Clear to auscultation all fields.

ABDOMEN: Soft, nontender, nondistended. Bowel sounds present. No hepato- or

splenomegaly.

AIRWAY: Malampati III, Thyromental distance 6 cm. Good mouth opening. Cx spine:
full range of motion. Normal teeth.

The patient is extremely anxious. He has heard that general anesthesia is dangerous
and insists on the procedure being performed under spinal anesthetic.
Team Training: Unanticipated Difficult Airway 23
 Appendix B: Debriefing Questions
Debriefing Questions. General points:
The Basic Assumption for the debriefing is:
We believe that everyone participating in the simulation scenario is intelligent, well-
trained, cares about doing their best, and wants to improve.
 Critique the performance, not the individual
 Ask open ended questions – avoid yes/no questions

Framework for debriefing:

A. Reactions
 Clear the air and set the stage for discussion
 Facts

1) What happened?
 Participants often want to know "the answer"
 Stick to the facts
2) How did you feel about that?
 Accept expressions of feelings
- Acknowledge is not the same as agree
- Try to mirror feelings rather then evaluate them
- Don't tell participants "that's OK" when it may not be
 Give perspective if participant feelings are hurt. e.g.:
- I've seen this a dozen times and that happens nearly every time ... or
- I've made the same mistake ... or
- We all make mistakes and this is a good place to learn from them or ...
- Remind them of the Basic Assumption and say that we’ll work together
to figure out what happened ... or ...

B. Understanding
Remember to use Advocacy-Inquiry: be curious!
 Exploring
 Applying
 Generalizing

1) Exploring
 What were you thinking at the time?
 It looked to me like …..
(Use this to discuss some error you observed and would like to find out why
the student chose a particular course of action)
 How do you account for that?
 Why did that happen?
 What led to it? What next?
2) Applying
 What drug or procedure or behavior might be best?
 Have you ever done this clinically?
 How might this be reflected in your clinical practice?
3) Generalizing
 Have you ever seen anything similar to this in your practice?
 Are there analogies to the clinical world?
 What can be done in analogous situations?
Team Training: Unanticipated Difficult Airway 24
 Appendix B: Debriefing Questions (cont.)
C. Summary
Review what was learned and ensure the single scenario is put into a larger
context.
1) Relate this experience to higher level principles, e.g., principles of
teamwork, circulation and respiration, patient safety, etc.
2) What did you do well?
3) What would you do differently?

Specific crew resource management topics to discuss using this template:

1. Team leader’s performance:

 Was a team leader clearly identified?
 Were team members assigned to do specific tasks assigned
appropriately?
 Did he/she maintain awareness of the big picture? i.e. not
sidetracked
 Did the most life threatening issues get dealt with first?
ABC
 Did he/she allow team members to participate in the decision
making process?
 Were there any communication problems? i.e. not addressing
specific person, no parroting, miscommunication
 Did he/she use other resources appropriately i.e. non anesthesia
personnel?
2. Team members:
 Did he/she clearly communicate critical information to the team
leader & other team members?
 Did he/she request assistance if unable to complete task/during
task overload?
 Good communication: closed loop communication/parrot back,
clarify instructions, verbalize activities
3. Group performance:
 Was everyone involved in the crises?
 Were there any fixation errors?
 Were there any conflicts? If so, was it resolved?
 Did the team address new emergent events effectively?
 What communication problems did we see?
- Get person’s attention
- Make eye contact
- Use names if possible
- Parrot requests and responses
- Use cross-checks and ‘call-outs’
 Handover:
- S – Situation:
I need you NOW for an airway emergency
- B – Background:
55yr old male; failed spinal for ankle surgery; rapid
sequence induction
- A – Assessment:
can’t intubate can’t ventilate
- R – Recommendation
need help with airway management
Team Training: Unanticipated Difficult Airway 25
 Appendix B: Debriefing Questions (cont.)

Specific clinical management topics (i.e. issues from checklist which were
missed):

1. Any issues doing spinal?

2. Escalating sedation requirements
3. Option for dealing with a failed regional technique
4. Was a rapid sequence induction done due to full stomach?
5. Discuss contraindications for a rapid sequence induction such as a known
difficult airway. (In this scenarion, there is nothing to suggest a difficult airway.)
6. Any deviations from the difficult airway algorithm?
7. Was someone assigned to record events during the crises? This person can
watch for repeated intubation attempts. Attempts should not last longer than 30
seconds and the recorder can help by notifying the anesthesiologist when the
intubation time exceeds 30 seconds.
The recorder is particularly useful in this scenario however it is often forgotten
even it there is suffient personnel available.
8. Were there any fixation errors i.e. persisting with intubation / placing LMA?
9. Was a surgical airway established in a timely fashion?

Additional topics:

1. What would your further management of the patient have been? i.e. talk to
family, ICU care, extubation, etc.

2. Did it feel real? How can we improve this scenario?

3. Review importance of accurate record keeping, review the record – lapses in

vital signs, drugs administered.

Team Training: Unanticipated Difficult Airway 26

 Appendix C: Suggested Clinical Questions
Anesthesia Knowledge

a. Review definition of difficult:

 Ventilation
 Intubation
 Laryngoscopy

b. How would you assess the potential for:

 Difficult bag mask ventilation?
 Difficult intubation?

c. How would either of these influence what you do?

d. Review ASA difficult airway algorithm

e. Discuss what equipment is useful or not useful in this particular situation

f. Review closed claims recommendation – don’t delay proceeding to surgical

airway if all else fails, have plan B [Management of the Difficult Airway -
A Closed Claims Analysis: Anesthesiology 2005; 103:33–9]

Anesthesia Skills

a. Spinal anesthesia – technique

b. Rapid sequence induction
c. Bag mask ventilation: ensure proper technique
d. Proper use of oral & nasal airway
e. LMA
f. Laryngoscopy
g. Cricothyroidotomy

Case Hand-Over

Essential elements of an adequate case hand-over

Intra-operative Communication

a. Essential elements of routine intra-operative communication:

- Eye-contact, parroting responses, conveying urgency
b. Essential elements of intra-operative critical event communication – with
nurses, surgeons, ancillary help
- Eye-contact, parroting responses, conveying urgency

Team Training: Unanticipated Difficult Airway 27

 APPENDIX D: Equipment Set Up

Spinal Simulator
LP simulator set up with water
Spinal needles: 22G, 24G, 25G, 27G
Introducer needle
Regional tray (unopened)
Chlorhexidine solution
Gloves

Drugs
Bupivacaine
(2cc 0.75% with dextrose, 20cc 0.5% plain, 20cc 0.25% plain)
Lidocaine (30cc 1% plain, 5cc 2% plain)
Setup the spinal simulator in the room with SimMan

Anesthesia Machine
SimMan in hospital gown, on OR bed (head on ‘donut’)
Voice
IV pole
IV line in situ
Monitoring: NIBP, EKG, Oxygen saturation probe
Gas analysis: End tidal CO2 monitoring
Propofol syringe pump
Full oxygen cylinder on machine
Ambu bag-mask system
Gloves
O2 Mask
Suction
Temperature probe
Emergency drugs
Antibiotics
ECG dots
Routine OR monitors

Team Training: Unanticipated Difficult Airway 28

 APPENDIX D:
Equipment Set Up (cont.)
Anesthesia Machine (continued)

IV in arm with fluid line attached

Suction canister with Yanker tip
Propofol infusion line
Full oxygen cylinder with flow meter

Surgery
Drapes
Tourniquet

Patient History and Physical Sheet on Clip Board

Drugs
Anesthesia cart fully supplied
Propofol (10 mg/ml) 20 ml syringe X 2
Fentanyl (50 mcg/ml) 5ml syringe X 3
Midazolam (1 mg/ml) 2 ml syringe X 1
Etomidate (2mg/ml) 10 ml syringe X 2
Ketamine (10mg/ml) 20ml syringe X 1
Succinylcholine (20mg/ml) 10ml in 20ml syringe X 2
Rocuronium (10mg/ml) 5ml syringe X 2
Kefzol (1 gm/250 ml) syringe X 1
Ephedrine (5mg/ml) 5ml in 10ml syringe X 1
Phenylephrine (200mcg/ml) 10 ml syringe
Atropine (0.4mg/ml) 2.5ml in a 5 ml syringe

Code cart – in operating room, fully stocked

Vasopressin / Epinephrine
Amiodarone / Lidocaine
Adenosine – 5 ml syringes (2 mg/ml) X 2
Ambubag
Gloves

Team Training: Unanticipated Difficult Airway 29

 APPENDIX D:
Equipment Set Up (cont.)
Difficult Airway Kit

Combitube (This may not be available)

LMA’s sizes 3, 4 & 5
Intubating LMAs sizes 3, 4 & 5
Endotracheal tubes size 6.5, 7.0 7.5, 8.0
Different laryngoscope blades
Macintosh 3 & 4
Miller 2 & 3
Fiber optic scope
Oral airways (green, yellow, red)
Nasal airways (28, 32, 34)
Introducer / stylet
Eschmann Stylet / Gum elastic bougie
Cricothyroidotomy kit
Retrograde kit
Jet ventilation system
Lighted stylet
Lubricant

Team Training: Unanticipated Difficult Airway 30

 APPENDIX E: Performance Checklist

Pre-Op Assessment, Anesthesia Planning & Spinal

_____Confirm Id: Patient’s name

_____Patient’s procedure
_____Patient’s allergies
_____Patient’s medications – emphasis on anticoagulation meds
_____Patient’s medical problems incl. bleeding tendencies
_____Assess potential for full stomach
pain / opioids / time between last meal & accident
_____Other injuries
_____Airway examination*
_____Verify consent
_____Ensure adequate IV
_____Prepare equipment for spinal
_____Appropriate monitoring
_____Appropriate emergency equipment & drugs
_____Use iliac crest to identify L4
_____Appropriate skill in placing spinal
_____Appropriate dose of local anesthetic for level of surgery

Sedation

_____No escalation of sedation – full stomach

_____Stop surgery / release tourniquet
_____Proceed to RSI*
_____Proper RSI technique

Team Training: Unanticipated Difficult Airway 31

 APPENDIX E: Performance Checklist (cont.)

Upper airway obstruction

_____100% O2*
_____Call for help*
_____Brief description of problem
_____Attempt bag mask ventilation* – one person
_____Attempt bag mask ventilation – two person
_____Use oral / nasal airway
_____Attempt LMA
_____Attempt intubation not more than 2 X
_____Do not repeat failed technique* – change something ie different blade,
optimize position
_____Call for difficult airway cart*
_____Proceed to surgical airway*
_____Review plan for end of case (i.e. to PACU or ICU, extubation)
_____Appropriate use of resources ie can surgeon perform surgical airway

Upper airway obstruction

_____100% O2*
_____Call for help*
_____Brief description of problem
_____Attempt bag mask ventilation* – one person
_____Attempt bag mask ventilation – two person
_____Use oral / nasal airway
_____Attempt LMA
_____Attempt intubation not more than 2 X
_____Do not repeat failed technique* – change something ie different blade,

* Bold items are critical steps

Team Training: Unanticipated Difficult Airway 32

 APPENDIX F: Team Evaluation Form

Date: Team Members

Time:
Evaluator:

Rating
Strongly Disagree / Strongly Agree 1-5
N/A: n/a

Team leader:

1. Command authority / leader clearly recognized by

team members. 1 2 3 4 5 n/a
2. Maintains situational awareness – do not get
side tracked, reassess situation. 1 2 3 4 5 n/a
3. Assign team members appropriately 1 2 3 4 5 n/a
4. Prioritize appropriately 1 2 3 4 5 n/a
5. Engage team members in decisions 1 2 3 4 5 n/a
6. Good communication i.e. address specific persons
when requesting info or assigning tasks. 1 2 3 4 5 n/a
7. Monitors actions of team members 1 2 3 4 5 n/a
8. Balance team workload 1 2 3 4 5 n/a
9. Resource management i.e. use non anesthesia
personnel. 1 2 3 4 5 n/a
10. Appropriate handover / description of problem
to new attending. 1 2 3 4 5 n/a

Team member:
1. Clear understanding of his/her role. 1 2 3 4 5 n/a
2. Verbalize observations/errors/critical info. 1 2 3 4 5 n/a
3. Ask for assistance if unable to complete
task/during task overload. 1 2 3 4 5 n/a
4. Good communication: closed loop
communication/parrot back, clarify instructions,
verbalize activities. 1 2 3 4 5 n/a

Team Training: Unanticipated Difficult Airway 33

 APPENDIX F: Team Evaluation Form

Group:
1. Everyone involved in crises. 1 2 3 4 5 n/a
2. Avoid fixation errors. 1 2 3 4 5 n/a
3. Resolves conflicts/disagreements. 1 2 3 4 5 n/a
4. Roles are shifted to address urgent or
emergent events, when appropriate. 1 2 3 4 5 n/a

Overall assessment for each participant:

This person functioned as an effective team

leader or team member : 1 2 3 4 5 n/a

Team Training: Unanticipated Difficult Airway 34

 APPENDIX G: Simulation Experience
Evaluation Form

Rating:
Strongly disagree  strongly agree 1-5
NA 0

Simulation Evaluation

1) Learners should spend more time working

in the simulator 1 2 3 4 5 n/a

2) The course enhanced my understanding of how to handle critical

incidents situations and crisis 1 2 3 4 5 n/a

3) The simulation was an effective educational tool

1 2 3 4 5 n/a

4) The simulation experience provides a realistic model of working

in a clinical setting 1 2 3 4 5 n/a

5) The debriefing session was an important learning opportunity

1 2 3 4 5 n/a

6) What issue(s) would you like addressed in future simulation sessions?

_____________________________________________________________
_____________________________________________________________
7) Comments:
_____________________________________________________________

Team Training: Unanticipated Difficult Airway 35

 APPENDIX H: Content and Instructor
Evaluation Form
Rating:
Strongly disagree  strongly agree 1-5
NA 0

Content Evaluation
1) The content was:
a) Current 1 2 3 4 5 n/a
b) Best practice 1 2 3 4 5 n/a
c) Free of bias 1 2 3 4 5 n/a
d) Relevant to my practice 1 2 3 4 5 n/a
2) I will change my practice based on the
i) information presented 1 2 3 4 5 n/a
3) The educational level of this activity
i) was appropriate 1 2 3 4 5 n/a
4) The most important concept learned during this session that may
contribute to a change in patient care is:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Instructor Evaluation

1) The instructor had a good command of the content 1 2 3 4 5 n/a

2) The instructor’s presentation was clear & concise 1 2 3 4 5 n/a
3) The instructor clearly demonstrated the required
skills 1 2 3 4 5 n/a
4) The instructor created a safe environment for
the debriefing 1 2 3 4 5 n/a
5) The instructor was an effective facilitator 1 2 3 4 5 n/a
6) The instructor feedback was helpful 1 2 3 4 5 n/a
7) Overall, the instructor contributed to my learning 1 2 3 4 5 n/a
8) Comments:
__________________________________________________________
________________________________________________________________
________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Team Training: Unanticipated Difficult Airway 36

 APPENDIX I: References

1. Practice Guidelines for Management of the Difficult Airway: Anesthesiology

2003; 98:1269–77
http:// www.asahq.org/publicationsAndServices/Difficult%20Airway.pdf

2. Miller, CG: Management of the Difficult Intubation in Closed Malpractice Claims.

ASA Newsletter 64(6):13-16 & 19, 2000

3. Management of the Difficult Airway - A Closed Claims Analysis: Anesthesiology

2005; 103:33–9

4. Standards for Basic Anesthetic Monitoring (Approved by ASA House of

Delegates 10/21/86 and last amended 10/27/04)

5. ASA Guidelines for Regional Anesthesia in Obstetrics (Approved by the ASA

House of Delegates on October 12, 1988, last amended on October 18, 2000)

6. Malec JF, Torsher LC, Dunn WF, Wiegmann DA, Arnold JJ, Brown DA, Phatak
V: The Mayo High Performance Teamwork Scale: Reliability and Validity for
Evaluating Key Crew Resource Management Skills. Simulation in Healthcare:
The Journal of the Society for Simulation in Healthcare. 2(1):4-10, Spring 2007.

Team Training: Unanticipated Difficult Airway 37

 Appendix J: Scenario flow sheet (1)

Team Training: Unanticipated Difficult Airway 38

 Appendix J: Scenario flow sheet (2)

Team Training: Unanticipated Difficult Airway 39