AIRWAY MANAGEMENT IN

EMERGENCIES
• The ABCs (Airway, Breathing and Circulation) form the foundation of the initial
response to critically ill patients. Initial airway assessment involves evaluating for
airway obstruction or patency which can be determined by assessing for snoring,
stridor, drooling, hoarseness, edema, and facial trauma or burns
• A 'definitive airway' is generally defined as a cuffed tube placed below the glottis. However, a

variety of airway devices and adjuncts are available to relieve or prevent upper airway

obstruction.

• Airway adjuncts provide a conduit for ventilation, oxygenation, and suctioning and can be

used with bag-valve-mask (BVM) ventilation

• Another airway adjunct is the nasopharyngeal airway (NPA). NPAs, like the OPA, can help

prevent upper airway obstruction. The NPA can be used in a conscious patient with an intact

gag reflex.

• Due to the risk for epistaxis or nasopharyngeal injury, NPAs are contraindicated in patients

who are anticoagulated; have basilar skull fractures, nasal deformities or nasal infections
 Bag-Valve Mask

Bag-valve-mask (BVM) ventilation is the most important skill in basic airway

management. Simple maneuvers and basic airway adjuncts can ensure a patent airway
and allow for effective oxygenation and ventilation until a more definitive airway is
established. BVM ventilation requires a good mask seal and a patent airway.
• While providing BVM ventilation, extend the patient's head slightly using the head-
tilt chin-lift maneuver.

• Place an OPA or NPA to assist with ventilations. The mask should cover the nose
and mouth without extending over the chin. The mask is held in place with the
one-handed E-C technique. Using the nondominant hand
• The two-handed technique is preferred if a second person is available to provide
ventilations

• Alternatively, place both thumbs opposing the mask connector and use the thenar
eminence to hold the mask to the face while lifting the mandible with the fingers
• Endotracheal intubation is a critical, often lifesaving procedure for severely ill or injured

patients who cannot maintain adequate oxygenation, perform effective ventilation, or

maintain a protected airway

• Proper airway management requires a thorough understanding of the indications for tracheal

intubation, the pharmacology of sedative and neuromuscular-blocking agents used in rapid

sequence intubation (RSI), and the proper methods for endotracheal tube placement
• Preparation is key to the success of endotracheal intubation. Frequently it
is helpful to establish an 'airway cart' or an 'airway toolbox' stocked with
all necessary equipment including size ranges
 The choice of blade
depends on personal
preference and patient
anatomy.

The laryngoscope is a rigid instrument

used to facilitate intubation of the
trachea. The two main components
are a cylindrical handle and the blade
• Prior to intubation, the individual performing the procedure should verify that all

necessary equipment is available and functioning properly

• Rescue or assistive devices such as the bougie, laryngeal mask airway (LMA), video

laryngoscope, or surgical cricothyrotomy kit (shown) should also be available

• Preoxygenation is an effective method to establish a pulmonary oxygen reservoir
and thus prolong the time before hypoxia in non-breathing patients

• Gastric inflation can occur when the bag is squeezed too forcefully or too quickly.
The ventilatory rate should not exceed 10-12 breaths per minute. Use a tidal
volume of approximately 8-10 mL/kg or just large enough to cause chest rise
• A difficult airway assessment must be performed before attempting intubation,
especially when using neuromuscular-blocking agents. The mnemonic "LEMON" is
a helpful tool to assess the likelihood of a patient having a difficult airway.
• The "M" in the "LEMON" mnemonic is for Mallampati classification,
which is performed with the patient seated and neck extended.
Open the patient's mouth fully; protrude the patient's tongue
• "O" is for Obstruction. Evaluation for foreign bodies, stridor,
and other forms of sub- and supraglottic obstruction should
be performed in every patient prior to laryngoscopy
• "N" is for Neck mobility. Patients with degenerative or rheumatoid arthritis
may have limited neck motion, and this should be assessed to ensure the
ability to adequately extend the neck during laryngoscopy and intubation
• Acceptable neck extend is about 35˚
• RSI maximizes the rate of successful intubation, decreases the risk for aspiration, and offers

better C-spine control. The risks of undertaking RSI should be well understood, including

prolonged intubation time, adverse drug effects, and development of a crash airway

• Adequately assessing the ability to ventilate a patient via BVM is essential prior to the

provision of paralytics
• The modified jaw-thrust technique (shown) can be employed in patients in
whom a cervical spine injury is suspected. When properly performed, it
can be accomplished without extending the neck.
Once the patient is
preoxygenated, sedated, and
paralyzed (actual paralysis
may not be immediate, as in
the case of succinylcholine,
and monitoring for the
termination of muscle
fasciculations is helpful to
determine the time of actual
paralysis)
• Once the ETT has passed
through the vocal cords, the
stylet is carefully removed
and the distal balloon cuff
inflated with a 5- to 10-
cm3 syringe

• In RSI, we release the cricoid

pressure once comfirmed that
ETT is in the right place (in
the trachea)
A postintubation chest
x-ray does not confirm
tube placement, but
will evaluate the depth
of ETT
• The LMA is used as a
rescue airway device to
ventilate patients when
traditional endotracheal
intubation is not
feasible
• Video laryngoscopy affords more
grade 1 and 2 views than direct
laryngoscopy and improves glottic
exposure in most patients with poor
direct glottic visualization
• Video laryngoscopy affords more grade 1 and 2 views than direct laryngoscopy and improves
glottic exposure in most patients with poor direct glottic visualization

• Indications for video laryngoscopy include morbid obesity, poor direct laryngoscopic view
from trauma or anatomic variation, inability to view the vocal cords, small mouth opening (<
3 cm), limited neck extension, or suspected cervical spine injury
 If oral intubation has failed and you are
unable to oxygenate or ventilate using
an airway adjunct, a surgical
cricothyroidotomy may be employed to
establish airway control

Indications :
• massive oral, nasal, or pharyngeal
hemorrhage and/or trauma
• masseter muscle spasm
• structural deformities of the
oropharynx
• stenosis of the upper airway
• Laryngospasm
• mass or tumor
• oropharyngeal edema.