J U LY 2 0 1 7 O U T P A T I E N TS U R G E R Y. N E T 1 5
In his role as an adjunct clinical associate
professor of anesthesia at Stanford
University, Rick Novak, MD, teaches a slight
adjustment to one of medicine's most endur-
ing mnemonics. "In critical care medicine,
you focus on ABC — airway, breathing, cir-
culation," says Dr. Novak. "I teach the impor-
tance of the mnemonic airway, airway, air-
way. You simply can't afford to lose a
patient's airway. In a 'can't-intubate, can't-
ventilate' scenario, you have 5 minutes to
oxygenate the patient before there's a very
real risk of permanent brain damage."
This is why Dr. Novak considers bag-mask
ventilation the most vital airway skill. Even in
patients who have unexpectedly difficult intuba-
tions, mask ventilation can keep the patient
oxygenated while the anesthesiologist deter-
mines the best option to proceed.
"You need a plan," he says. Or, in his case,
the 4 plans — A, B, C and D — included in the
system first proposed by C. Philip Larson Jr.,
MD, professor emeritus at Stanford University
and one of Dr. Novak's past professors and
mentors in the area of airway management.
Dr. Larson's "A through D" system serves as
a "cascading recipe" for avoiding airway disas-
ters:
• Plan A: Employ direct laryngoscopy using a
Miller or Macintosh blade.
• Plan B: Use a video laryngoscope to secure
the airway.
• Plan C: Intubate through a supraglottic air-
way using a fiber-optic bronchoscope.
• Plan D: Stop the anesthetic, wake the
patient and reschedule the case for another day
when awake fiber-optic intubation would be
used. If the operation cannot be postponed,
perform a tracheostomy.
"The simplest, safest option that works is
the preferred method for maintaining an air-
way," says Dr. Novak. "That's why the cascade
is so practical." — Bill Donahue
BACKUP PLAN
The ABC(&Ds) of Airway Management
• STEP BY STEP A "cascade" airway
management plans starts with the
simplest and safest option.
Pamela
Bevelhymer,
RN,
BSN,
CNOR
