PDF Hungs Difficult and Failed Airway Management Orlando Hung Ebook Full Chapter

Hung’s Difficult and Failed Airway
Management Orlando Hung

Visit to download the full and correct content document:
https://textbookfull.com/product/hungs-difficult-and-failed-airway-management-orland
o-hung/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Management of the Difficult Pediatric Airway Narasimhan

Jagannathan
https://textbookfull.com/product/management-of-the-difficult-
pediatric-airway-narasimhan-jagannathan/
Frontier Computing Theory Technologies and Applications

FC 2018 Jason C. Hung
https://textbookfull.com/product/frontier-computing-theory-
technologies-and-applications-fc-2018-jason-c-hung/
A First Course in Fuzzy Logic 4th Edition Hung T.

Nguyen
https://textbookfull.com/product/a-first-course-in-fuzzy-
logic-4th-edition-hung-t-nguyen/
Research Methods in English Medium Instruction 1st

Edition Jack Kwok-Hung Pun
https://textbookfull.com/product/research-methods-in-english-
medium-instruction-1st-edition-jack-kwok-hung-pun/
The State of China’s State Capitalism: Evidence of Its
Successes and Pitfalls Juann H. Hung
https://textbookfull.com/product/the-state-of-chinas-state-
capitalism-evidence-of-its-successes-and-pitfalls-juann-h-hung/
Science Education Research and Practices in Taiwan

Challenges and Opportunities 1st Edition Mei-Hung Chiu
(Eds.)
https://textbookfull.com/product/science-education-research-and-
practices-in-taiwan-challenges-and-opportunities-1st-edition-mei-
hung-chiu-eds/
Angry White People Coming Face to Face with the British

Far Right 1st Edition Hsiao-Hung Pai
https://textbookfull.com/product/angry-white-people-coming-face-
to-face-with-the-british-far-right-1st-edition-hsiao-hung-pai/
Core Topics in Airway Management Cambridge Medicine

Tim Cook
https://textbookfull.com/product/core-topics-in-airway-
management-cambridge-medicine-tim-cook/
Distributed Computing and Internet Technology 16th

International Conference ICDCIT 2020 Bhubaneswar India
January 9 12 2020 Proceedings Dang Van Hung
https://textbookfull.com/product/distributed-computing-and-
internet-technology-16th-international-conference-
icdcit-2020-bhubaneswar-india-january-9-12-2020-proceedings-dang-
Hung's
DIFFICULT
AND FAILED
AIRWAY
MANAGEMENT
NOT IC E
Medicine is an ever-changing science. As new research and clinical experience broaden our knowl
edge, changes in treatment and drug therapy are required. The authors and the publisher of this
work have checked with sources believed to be reliable in their efforts to provide information that is
complete and generally in accord with the standards accepted at the time of publication. However,
in view of the possibility of human error or changes in medical sciences, neither the authors nor
the publisher nor any other party who has been involved in the preparation or publication of this
work warrants that the information contained herein is in every respect accurate or complete, and
they disclaim all responsibility for any errors or omissions or for the results obtained from use of the
information contained in this work. Readers are encouraged to confirm the information contained
herein with other sources. For example and in particular, readers are advised to check the product
information sheet included in the package of each drug they plan to administer to be certain that the
information contained in this work is accurate and that changes have not been made in the recom
mended dose or in the contraindications for administration. This recommendation is of particular
importance in connection with new or infrequently used drugs.
THIRD EDITION
Hung's
DIFFICULT
AND FAILED
AIRWAY
MANAGEMENT
ORLA N DO R. HU N G, B S c ( PHARMACY), M D, FRC P (C)

Professor, Departments of Anesthesia, Surgery, and Pharmacology
Director of Research
Department of Anesthesia, Pain Management and Perioperative Medicine
Dalhousie University
Queen Elizabeth II Health Sciences Centre
Department of Anesthesia
Halifax, Nova Scotia, Canada
MICHA EL F. MURPHY, M D, FRC P (C)

Professor Emeritus, Department of Anesthesiology and Pain Medicine
University of Alberta
Walter C Mackenzie Health Sciences Centre
Edmonton, Alberta, Canada
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
Copyright© 2018 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States
Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means,
or stored in a database or retrieval system, without the prior written permission of the publisher.
ISBN: 978-1-25-964055-1
MHID: 1-25-964055-8
The material in this eBook also appears in the print version of this title: ISBN: 978-1-25-964054-4,
MHID: 1-25-964054-X.
eBook conversion by codeMantra

Version 1.0
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occur
rence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner,
with no intention of infringement of the trademark. Where such designations appear in this book, they have been
printed with initial caps.
McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promo
tions or for use in corporate training programs. To contact a representative, please visit the Contact Us page at
www.mhprofessional.com.
TERMS OF USE
This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use
of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store
and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify,
create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any
part of it without McGraw-Hill Education's prior consent. You may use the work for your own noncommercial
and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if
you fail to comply with these terms.
THE WORK IS PROVIDED "AS IS." McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO
GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR
RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN
BE ACCESSED THROUGH THE WORK VIA HY PERLINK OR OTHERWISE, AND EXPRESSLY DIS
CLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WAR
RANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Education
and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements
or that its operation will be uninterrupted or error free. Neither McGraw-Hill Education nor its licensors shall
be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any
damages resulting therefrom. McGraw-Hill Education has no responsibility for the content of any information ac
cessed through the work. Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for
any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability
to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liabil
ity shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
ASSOCIATE EDITORS
Thomas J . Coonan, M D, F RC P (C) J. Ada m Law, M D, F RC P (C)

Professor, Departments of Anesthesia and Surgery Professor, Departments of Anesthesia and Surgery
Dalhousie University Associate Head
Queen Elizabeth II Health Sciences Centre Department of Anesthesia, Pain Management and Perioperative
Department of Anesthesia Medicine
Halifax, Nova Scotia, Canada Faculty of Medicine, Dalhousie University
N a ra s i m h a n Jagan nathan, M D Halifax, Nova Scotia, Canada
Associate Chairman, Academic Affairs
Director, Pediatric Anesthesia Research la n R. Morris, B Eng, M D, F RC P(C), DABA, FAC E P
Ann & Robert H. Lurie Children's Hospital of Chicago Professor, Department of Anesthesia
Associate Professor of Anesthesiology Dalhousie University
Northwestern University Feinberg School of Medicine Queen Elizabeth II Health Sciences Centre
Chicago, Illinois Department of Anesthesia
George Kovacs, M D, FRCP(C)
Professor, Emergency Medicine Ron a l d D. Stewa rt, OC, O N S, E C N S (hon), BA, BSc, M D,
Dalhousie University FACEP, DSc (hon)
Attending Emergency Physician Professor Emeritus
Nova Scotia Health Authority Departments of Anesthesia and Emergency Medicine
Queen Elizabeth II Health Sciences Centre Faculty of Medicine, Dalhousie University
Halifax, Nova Scotia, Canada Queen Elizabeth II Health Sciences Centre
Victoria General Hospital Site
DEDICATION
We would like to thank our families for their understanding and support of our aca
demic and clinical work by dedicating this edition to: Jeanette, Christopher, David,
and Ana Hung and to Debbi, Amanda, Ryan, and Teddy Murphy. We also dedicate
this edition to the tireless efforts of all who teach airway management. We are grateful
for their commitment to the prevention of death and disability related to airway man
agement failure.
CON TEN TS
Contributors .................................................................................... xiii
Foreword ........................................................................................xix
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi
Acknowledgments ............................................................................. xxiii
PRINCIPLES OF AIRWAY MANAGEMENT
1. Evaluation of the Airway .... . . . .....

. . . . . . 2 4. Pharmacology of Drugs Used
Michael F Murphy and in Airway Management . . . . . . . . . . . . . . . . . . 86
Johannes M. Huitink Jonathan G. Bailey, Ronald B. George,
and Orlando R. Hung
2. The Algorithms . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Michael F Murphy, Edward T. Crosby, 5. Aspiration: Risks and Prevention ..... . . . 107
and J. Adam Law Saul Pytka and Edward Crosby
3. Preparation for Awake Intubation .... . . . . 39 6. Human Factors and Airway

/an R. Morris Management .... . . . . . . ....
. . . . . . ..... .128 .
Peter G. Brindley
AIRWAY TECHNIQUES
7. Context-Sensitive Airway 10. Flexible Bronchoscopic Intubation ... . . .172

Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 /an R. Morris
Orlando R. Hung and Michael F Murphy
11. Rigid Fiberoptic and
8. Bag- Mask-Ventilation .. .... . . . . . . .... . . .1 4 3 Video-Laryngoscopes . . . . . . . . . . . . . . . . . . . 198
George Kovacs, Michael F Murphy, and Richard M. Cooper and J. Adam Law
Nicholas Sowers
12. Nonvisual Intubation Techniques .... . . .222
9. Direct Laryngoscopy . . . . . . . . . . . . . . . . . . . . 155 Chris C. Christodoulou, Orlando R. Hung,
Richard M. Levitan and George Kovacs and Jinbin Zhang
vii
viii Contents
1 3. Extraglottic Devices for Ventilation 14. Cricothyrotomy.........................259

and Oxygenation .......................238 Gordon 0. Launcelott, Liane B. Johnson,
Liem Ho, Thomas J. Coonan, and David T Wong, and Orlando R. Hung
Orlando R. Hung
15. Tracheotomy ...........................270
Timothy F. E. Brown and Liane B. Johnson
PRE-HOSPITAL AIRWAY MANAGEMENT
16. What Is Unique About Airway 19. Airway Management of a Race

Management in the Pre-Hospital Car Driver with a Full-Face Helmet
Setting? ................................278 Following a Crash.......................305
Mark Vu, David Petrie, Michael F. Murphy, Mark P Vu, Angelina Guzzo, and
and Erik N. Vu Orlando R. Hung
17. Airway Management of a Patient with 20. Airway Management of a Morbidly

Traumatic Brain Injury (T B I) .............287 Obese Patient Suffering from
J. Adam Law, Edward T Crosby, and Andy Jagoda a Cardiac Arrest.........................311
Saul Pytka and Danae Krahn
18. Airway Management of an
Unconscious Patient Who Is Trapped 21. Airway Management with Blunt
Inside the Vehicle Following a Motor Anterior Neck Trauma...................320
Vehicle Collision ........................300 David A. Caro
Arnim Vlatten and Matthias Helm
AIRWAY MANAGEMENT IN THE EMERGENCY ROOM
22. Airway Management in the 26. Airway Management in a Patient

Emergency Department ................326 with Angioedema ......................3 45
John C. Sakles and Michael F. Murphy Genevieve MacKinnon, Michael F. Murphy,
and David Petrie
23. Patient with Deadly Asthma Requires
Intubation ..............................3 31 27. Airway Management for Penetrating
Kerryann B. Broderick and Jennifer W Zhan Facial Trauma...........................350
David A. Caro and Aaron E. Bair
24. Tracheal Intubation in an Uncooperative
Patient With a Neck Injury...............3 37 28. Airway Management in a Patient
Kerryann B. Broderick with a Deep Neck Infection .............355
Kirk J. MacQuarrie
25. Airway Management for the
Burn Patient ............................3 41
Laeben Lester and Darren Braude
Contents ix
AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT (ICU)
29. Unique Airway Issues in the 32. Management of a Patient Admitted to

Intensive Care Unit .....................364 ICU with Ebola Virus and Impending
Shawn D. Hicks, J. Adam Law, and Respiratory Failure ......................38 3
Michael F. Murphy Louise Ellard and David T Wong
30. Management of Extubation of a Patient 3 3. Performing an Elective Percutaneous

Following a Prolonged Period of Dilational Tracheotomy in a Patient
Mechanical Ventilation..................370 on Mechanical Ventilation ..............390
Richard M. Cooper Angelina Guzzo, Liane B. Johnson,
and Orlando R. Hung
31. Airway Management of a Patient in a
Halo-Jacket with Acute Obstruction 3 4. Management of a Patient with
of a Reinforced Tracheal Tube...........377 a Respiratory Arrest in the
Dietrich Henzler Intermediate Care Unit..................400
Peter G. Brindley
AIRWAY MANAGEMENT IN THE OPERATING ROOM
35. Airway Management of an 41. Airway Management in a Patient with

Uncooperative Down Syndrome Aspiration of Gastric Contents
Patient with an Upper Gl Bleed..........408 Following Induction of Anesthesia ......46 3
Michael F. Murphy Kathryn Sparrow and Orlando R . Hung
36. Airway Management of a Patient 42. Airway Management of a Patient

with a History of Oral and Cervical with History of Difficult Airway
Radiation Therapy ......................413 Who Refuses to Have Awake
/an R. Morris Tracheal Intubation .....................469
Dmitry Portnoy and Carin A. Hagberg
37. Airway Management in Penetrating
Neck Injury .............................424 4 3. Management of a Patient with OSA
/an R. Morris for Total Thyroidectomy ................481
Jinbin Zhang, Frances Chung, and
38. Airway Management of a Patient
Orlando R. Hung
in Prone Position .......................4 40
Dennis Drapeau and Orlando R. Hung 4 4. Airway Management of a Patient
with a Difficult Airway Requiring
39. Lung Separation in the Patient
Microlaryngoscopy, Tracheoscopy,
with a Difficult Airway ..................450
and Pharyngoesophageal Dilation ......492
ian R. Morris
Jeanette Scott, David Vokes, and L V Duggan
40. Airway Management of a Patient with
Superior Vena Cava Obstruction
Syndrome ..............................457
Mathieu Asselin and Gordon 0. Launcelott
x Contents
AIRWAY MANAGEMENT IN THE PEDIATRIC POPULATION
45. Unique Airway Issues in the 48. Airway Management of a 6-Year-Oid

Pediatric Population ....................508 with Pierre Robin Syndrome for
Narasimhan Jagannathan, Andrea Huang, Bilateral Inguinal Hernia Repair ..........5 35
Anthony Longhini, and John Hajduk Ban C.H. Tsui
46. Management of a 12-Year-Oid 49. Cannot Intubate and Cannot

Child with a Foreign Body in Oxygenate in an Infant After
the Bronchus ...........................524 Induction of Anesthesia.................5 47
Liane B. Johnson Paul A. Baker and Cedric Ernest Sottas
47. Management of a Child with 50. A Neonate with a Difficult Airway

a History of Difficult Intubation and Aspiration Risk .....................555
and Post-Tonsillectomy Bleed ...........5 30 Andrea Huang, Sebastian Bienia, John Hajduk
Arnim Vlatten and Matthias Helm and Narasimhan Jagannathan
AIRWAY MANAGEMENT IN OBSTETRICS
51. What Is Unique About the Obstetrical 5 4. Airway Management of

Airway?.................................562 the Pregnant Trauma
Dolores M. McKeen and Jo Davies Victim ..................................585
Holly A. Muir
52. Airway Management of the Obstetrical
Patient with an Anticipated Difficult 55. Appendicitis in
Airway..................................57 4 Pregnancy ..............................589
Jo Davies and Brian K. Ross A/lana Munro, Ronald B. George and
Narendra Vakharia
5 3. Unanticipated Difficult Airway in an
Obstetrical Patient Requiring an
Emergency Cesarean Section ...........579
Holly A. Muir
Contents xi
AIRWAY MANAGEMENT IN UNIQUE ENVIRONMENT
56. Unique Challenges of Ectopic 59. Airway Management in Austere

Airway Management....................596 Environments ..........................619
Michael F Murphy Kelly McQueen, Alison B. Froese,
Thomas J. Coonan and Jinbin Zhang
57. Airway Management of the Patient
with a Neck Hematoma .................601 60. Respiratory Management in the
J. Adam Law and Kitt Turney Magnetic Resonance Imaging Suite .....628
Richard D. Roda and Andrew D. Milne
58. Airway Management Under Combat
Conditions .............................612 61. Post-Obstructive Pulmonary
Matthias Helm and Arnim Vlatten Edema ( P O P E) ..........................636
Matthew G . Simms and J . Adam Law
PRACTICAL CONSIDERATIONS IN AIRWAY MANAGEMENT
62. Difficult Airway Carts....................646 6 4. Teaching and Simulation for

Saul Pytka and Michael F Murphy Airway Management....................662
Brian Ross, Jo Davies, Sara Kim, and
6 3. Documentation of Difficult and Failed
Michael F Murphy
Airway Management....................656
Lorraine J. Foley, Michael F Murphy and
Orlando R. Hung
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
.
This page intentionally left blank
CON TRIBUTORS
Mathieu Asselin, MD, FRCP(C) Kerryann B. Broderick, BSN, MD

Department of Anesthesia Associate Professor, Department of Emergency Medicine
University of Laval Denver Health Medical Center
Universitaire de Quebec, Pavillon H6pital Enfant-Jesus University of Colorado, School of Medicine
Quebec, Quebec, Canada Denver, Colorado
Chapter 40 Chapters 23, 24
Jonathan G. Bailey, MD, MSc Timothy F.E. Brown, MD, FRCSC
Department of Anesthesia, Pain Management and Department of Otolaryngology
Perioperative Medicine Dalhousie University
Dalhousie University Queen Elizabeth II Health Sciences Centre
Queen Elizabeth II Health Sciences Centre Victoria General Site
Halifax, Nova Scotia, Canada Halifax, Nova Scotia, Canada
Chapter 4 Chapter I5
Aaron E. Bair, MD, MS David A. Caro, MD
Assistant Professor, Emergency Medicine Associate Residency Director
U.C. Davis Medical Center Assistant Professor
Sacramento, California Department of Emergency Medicine
Chapter 27 University of Florida Health Science Center-Jacksonville
Jacksonville, Florida
Paul A. Baker, MBChB, MD, FANZCA
Chapters 2I, 27
Clinical Senior Lecturer
Department of Anesthesiology Chris C. Christodoulou, MBChB, Cum Laude DA
University of Auckland, New Zealand (UK), FRCP(C)
Consultant Anaesthetist Assistant Professor in Anesthesia
Starship Children's Hospital Department of Anesthesia and Perioperative Medicine
Auckland, New Zealand University of Manitoba
Chapter 49 I.H. Asper Clinical Research Institute
Winnipeg, Manitoba, Canada
Sebastian Bienia, MD
Chapter I2
Department of Pediatric Anesthesia
Ann & Robert H. Lurie Children's Hospital of Chicago Frances Chung, MBBS, FRCP(C)
Fellow in Pediatric Anesthesiology Professor, Department of Anesthesiology
Northwestern University Feinberg School of Medicine University of Toronto
Chicago, Illinois Toronto Western Hospital
Chapter 50 Toronto, Ontario, Canada
Chapter 43
Darren Braude, MD, EMT-P, FACEP
EMS Section Chief/Fellowship Director Thomas J. Coonan, MD, FRCP(C)
Professor of Emergency Medicine Professor, Departments of Anesthesia and Surgery
University of New Mexico Dalhousie University
Corrales, New Mexica Queen Elizabeth II Health Sciences Centre
Chapter 25 Department of Anesthesia
Peter G. Brindley, MD, FRCP(C), FRCP, Edin
Chapters I3, 59
Adj unct Professor, Department of Anesthesiology and Pain
Medicine Richard M. Cooper, BSc, MSc MD, FRCP(C)
University of Alberta Hospital Professor, Department of Anesthesia
Walter C Mackenzie Health Sciences Center University of Toronto
Edmonton, Alberta, Canada Department of Anesthesia and Pain Management
Chapters 6, 34 Toronto General Hospital
Toronto, Ontario, Canada
Chapters II, 30
xiii
xiv Contri b utors
Edward T. Crosby, MD, FRCP(C) Angelina Guzzo, MD, PhD, FRCP(C)

Professor, Department of Anesthesiology Assistant Professor, McGill University Health Centre
University of Ottawa Department of Anesthesia
Ottawa Hospital-General Campus Montreal General Hospital
Ottawa, Ontario, Canada Montreal, Quebec, Canada
Chapters 2, 5, 11 Chapters 19, 33
Jo Davies, MBBS, FRCA Carin A. Hagberg, MD
Associate Professor, Department of Anesthesiology Joseph C. Gabel Professor and Chair
University of Washington Department of Anesthesiology
Seattle, Washington The University of Texas Medical School at Houston
Chapters 51, 52, 64 Medical Director of Perioperative Services
Memorial Hermann Hospital
Dennis Drapeau, BSc, MD, FRCP(C)
Houston, Texas
Staff Anesthesiologist/Assistant Professor
Chapter 42
Queen Elizabeth II Health Sciences Centre John Hajduk
Dalhousie University Clinical Research Coordinator
Halifax, Nova Scotia, Canada Department of Pediatric Anesthesia
Chapter 38 Ann & Robert H. Lurie Children's Hospital of Chicago
Chicago, Illinois
Laura Duggan, MD, FRCP(C)
Chapters 45, 50
Anesthesiology and Pediatrics
Assistant Professor Prof. Dr. med. Matthias Helm
Department of Anesthesiology, Pharmacology and Chief Emergency Medicine
Therapeutics Department of Anaesthesiology, Intensive Care Medicine,
University of British Columbia Emergency Medicine and Pain Therapy
Royal Columbian Hospital Armed Forces Hospital
New Westminster, British Columbia, Canada Ulm, Germany
Chapter 44 Chapters 18, 47, 58
Louise Ellard, MBBS, FANZCA, AdvPTEeXAM Dietrich Henzler, MD, PhD, FRCP(C)
Staff Anaesthetist Professor of Anesthesiology
Department of Anaesthesia Ruhr University Bochum, Germany
Austin Health Dalhousie University, Halifax, Nova Scotia, Canada
Victoria, Australia Department of Anesthesia, Surgical Critical Care, Emergency
Chapter 32 and Pain Medicine
Klinikum Herford
Lorraine J. Foley, MD
Schwarzenmoorstr, Herford, Germany
Clinical Assistant Professor of Anesthesia
Chapter 31
Tufts School of Medicine, Boston, Massachusetts
Winchester Anesthesia Associates Shawn D. Hicks, MD, MSc, FRCP(C)
Winchester Hospital Assistant Professor, Department of Anesthesiology
Department of Anesthesia University of Ottawa
Winchester, Massachusetts The Ottawa Hospital, Civic Campus
Chapter 63 Ottawa, Ontario, Canada
Chapter 29
Alison B. Froese, MD, BSc Med, FRCP(C)
Professor Emerita, Queen's University Liem Ho, MD
Departments of Anesthesiology, Pediatrics, and Physiology Department of Anesthesia
Kingston, Ontario, Canada Dalhousie University
Chapter 59 Queen Elizabeth II Health Sciences Centre
Ronald B. George, MD, FRCP(C)
Chapter 13
Assistant Professor, Women's & Obstetric Anesthesia
Department of Anesthesia, Pain Management and Andrea Huang, MD
Perioperative Medicine Department of Pediatric Anesthesia
Dalhousie University Ann & Robert H. Lurie Children's Hospital of Chicago
IWK Health Centre Instructor in Anesthesiology
Halifax, Nova Scotia, Canada Northwestern University Feinberg School of Medicine
Chapters 4, 55 Chicago, Illinois
Chapters 45, 50
Contri b utors xv
Johannes M. Huitink, MD, PhD Danae Krahn, BHSc (Hons), MD

Assistant Professor Anesthesiology Chief Resident
Department of Anesthesiology Anesthesiology Residency Training Program
VU University Medical Center Amsterdam Cumming School of Medicine
Founder Airway Management Academy University of Calgary
Amsterdam, The Netherlands Calgary, Alberta, Canada
Chapter 1 Chapter 20
Orlando R. Hung, BSc (Pharmacy), MD, FRCP(C) Gordon 0. Launcelott, MD, FRCP(C)
Professor, Departments of Anesthesia, Surgery, and Department of Anesthesia
Pharmacology Dalhousie University
Director of Research, Queen Elizabeth II Health Sciences Centre
Department of Anesthesia, Pain Management and Halifax, Nova Scotia, Canada
Perioperative Medicine Chapters 14, 40
J. Adam Law, MD, FRCP(C)
Professor, Departments of Anesthesia and Surgery
Associate Head
Department of Anesthesia, Pain Management and
Chapters 4, 7, 12, 13, 14, 19, 33, 38, 41, 43, 63
Perioperative Medicine
Narasimhan Jagannathan, MD Faculty of Medicine, Dalhousie University
Associate Chairman, Academic Affairs Queen Elizabeth II Health Science Centre
Director, Pediatric Anesthesia Research Halifax, Nova Scotia, Canada
Ann & Robert H. Lurie Children's Hospital of Chicago Chapters 2, 11, 17, 29, 57, 61
Associate Professor of Anesthesiology
Laeben Lester, MD
Northwestern University Feinberg School of Medicine
Assistant Professor
Chicago, Illinois
Co-Director, Johns Hopkins Airway Program
Chapters 45, 50
The Johns Hopkins University School of Medicine
Andy Jagoda, MD, FACEP Department of Anesthesiology and Critical Care Medicine
Professor and Chair Division of Cardiothoracic Anesthesia
Department of Emergency Medicine Affiliate Department of Emergency Medicine
Mount Sinai School of Medicine Baltimore, Maryland
New York, New York Chapter 25
Chapter 11
Richard M. Levitan, MD
Liane B. Johnson, MDCM, FRCSC, FACS Associate Professor, Emergency Medicine
Department of Otolaryngology Thomas Jefferson University
Dalhousie University Department of Emergency Medicine
Department of Pediatric Otolaryngology Philadelphia, Pennsylvania
IWK Health Centre Chapter 9
Anthony Longhini, MD
Chapters 14, 15, 33, 46
Department of Anesthesiology
Sara Kim, PhD Northwestern University Feinberg School of Medicine
Associate Professor, Department of Anesthesiology and Chicago, Illinois
Biolnformatics Chapter 45
University of Washington
Genevieve MacKinnon, MD, FRCP(C)
Seattle, Washington
Assistant Professor
Chapter 64
Department of Pain Management and Perioperative Medicine
George Kovacs, MD, MD, FRCP(C) Dalhousie University
Professor Emergency Medicine Attending Physician Anesthesiology
Dalhousie University Nova Scotia Health Authority
Attending Emergency Physician Queen Elizabeth II Health Sciences Centre
Nova Scotia Health Authority Halifax, Nova Scotia, Canada
Queen Elizabeth II Health Sciences Centre Chapter 26
Chapters 8, 9
xvi Contri buto rs
Kirk J. MacQuarrie, MD, FRCP(C) Michael F. Murphy MD, FRCP(C)

Departments of Anesthesia, Surgery and Emergency Medicine Professor Emeritus, Department of Anesthesiology and Pain
Dalhousie University Medicine
Queen Elizabeth II Health Sciences Centre University of Alberta
Victoria General Hospital Walter C Mackenzie Health Sciences Centre
Halifax, Nova Scotia, Canada Edmonton, Alberta, Canada
Chapter 28 Chapters 1, 2, 7, 8, 16, 22, 26, 29, 35, 56, 62, 63, 64
Dolores M. McKeen, MD, MSc, FRCP(C) David Petrie, MD, FRCP(C)
Professor Associate Professor of Emergency Medicine
Department of Anesthesia, Pain Management and Dalhousie University
Perioperative Medicine Attending Physician Emergency Medicine
Dalhousie University Nova Scotia Health Authority
IWK Health Centre Queen Elizabeth II Health Sciences Centre
Chapter 51 Chapter 16
Kelly McQueen, MD, MPH Dmitry Portnoy, MD
Professor, Department of Anesthesiology Associate Professor
Director, Vanderbilt Anesthesia Global Health & Department of Anesthesiology and Perioperative Care
Development Staff Anesthesiologist
Director, Vanderbilt Global Anesthesia Fellowship UC Irvine Medical Center
Affiliate Faculty, Vanderbilt Institute for Global Health Orange, California
Vanderbilt University Medical Center Chapter 42
Nashville, Tennessee
Saul Pytka, MD, FRCP(C)
Chapter 59
Associate Professor
Andrew D. Milne, BEng, MSc, MD, FRCP(C) Department of Anesthesiology
Assistant Professor, Department of Anesthesia University of Calgary
Dalhousie University Attending Anesthesiologist
Queen Elizabeth II Health Sciences Centre Rockyview Hospital
Halifax, Nova Scotia, Canada Calgary, Alberta, Canada
Chapter 60 Chapters 5, 20, 62
Jan R. Morris, BEng, MD, FRCP(C), DABA, FACEP Richard D. Roda, BEng, MASc, MD
Professor, Department of Anesthesia Department of Anesthesia, Pain Management and
Dalhousie University Perioperative Medicine
Queen Elizabeth II Health Sciences Centre Faculty of Medicine, Dalhousie University
Department of Anesthesia Queen Elizabeth II Health Sciences Centre
Chapters 3, 10, 36, 37, 39 Chapter 60
Holly A. Muir, MD, FRCP(C) Brian K. Ross, PhD, MD
Chair and Professor Professor, Department of Anesthesiology and Pain Medicine
Department of Anesthesiology, Executive Director Institute for Surgical and Interventional
Keck School of Medicine, Simulation
University of Southern California University of Washington
Los Angeles, California Seattle, Washington
Chapters 53, 54 Chapters 52, 64
Allana Munro, MD, FRCP(C) John C. Sakles, MD, FACEP
Women's & Obstetric Anesthesia Professor, Department of Emergency Medicine
Department of Anesthesiology, Dalhousie University University of Arizona College of Medicine
IWK Health Centre Tucson, Arizona
Halifax, Nova Scotia, Canada Chapter 22
Chapter 55
Contri b utors xvi i
Jeanette Scott, MBChB, FANZCA Kitt Turney, MD

Anesthesiologist Resident Anesthesiologist, Department of Anesthesia, Pain
Department of Anaesthesia and Pain Medicine Management and Perioperative Medicine
Middlemore Hospital Queen Elizabeth II Health Sciences Centre
Department of Cardiac and ORL Anaesthesia Halifax, Nova Scotia, Canada
Auckland City Hospital Chapter 57
Auckland, New Zealand
Narendra Vakharia, MD, FRCP(C)
Chapter 44
Associate Professor
Matthew G. Simms, MSc, MD, FRCP(C) Dalhousie University
Staff Anesthesiologist Halifax, Nova Scotia, Canada
Department of Anesthesia, Faculty of Medicine Chapter 55
Arnim Vlatten, MD
Associate Professor
Departments of Anesthesia, Pediatric Anesthesia, and
Chapter 61
Pediatric Critical Care
Cedric Ernest Sottas, MD Dalhousie University
Anaesthesia Fellow Queen Elizabeth II Health Sciences Centre
Department of Pediatric Anaesthesia Halifax, Nova Scotia, Canada
Starship Children's Hospital Chapters 18, 47, 58
Auckland, New Zealand
David Vokes, MBChB, FRACS
Chapter 49
Laryngologist, Head and Neck Surgeon
Nicholas Sowers, MD Department of Otorhinolaryngology
Resident, Emergency Medicine Auckland City Hospital
Dalhousie University Auckland, New Zealand
Halifax Infirmary Chapter 44
Erik N. Vu, CCP, MD, FRCP(C), DAvMed
Chapter 8
Assistant Professor, Faculty of Medicine, University of British
Kathryn Sparrow, BSc, MD, FRCP(C) Columbia
Department of Anesthesia Departments of Emergency and Critical Care Medicine
Memorial University of Newfoundland British Columbia Emergency Health Services
Faculty of Medicine Vancouver, British Columbia, Canada
St. John's, Newfoundland and Labrador, Canada Chapter 16
Chapter 41
Mark P. Vu, MD, FRCP(C)
Ronald D. Stewart, OC, ONS, ECNS (hon), BA, BSc., Assistant Professor
MD, FACEP, DSc (hon) Department of Anesthesiology, Pharmacology and
Professor Emeritus Therapeutics
Departments of Anesthesia and Emergency Medicine University of British Columbia
Faculty of Medicine, Dalhousie University Department of Anesthesiology
Queen Elizabeth II Health Sciences Centre Vancouver Island Health Authority
Victoria General Hospital Site Victoria, British Columbia, Canada
Halifax, Nova Scotia, Canada Chapters 16, 19
Ban C. H. Tsui, Dip Eng, BSc(Math), BSc(Pharm), David T. Wong, MD, FRCP(C)
MSc(Pharm), MD, FRCP(C), PG Dip Echo Associate Professor
Professor of Anesthesiology Department of Anesthesia
Department of Anesthesiology, Preoperative and Pain Toronto Western Hospital
Medicine University of Toronto
Stanford University School of Medicine Toronto, Ontario, Canada
Stanford, California Chapters 14, 32
Chapter 48
xvi i i Contri butors
Jennifer W. Zhan, MD Jinbin Zhang, MBBS, MMED (Anaesthesiology)

Resident in Emergency Medicine Consultant, Tan Tock Seng Hospital
Denver Health Medical Center Clinical Lecturer, Yong Loo Lin School of Medicine
Denver, Colorado National University of Singapore
Chapter 23 Tan Tock Seng Hospital
Singapore
Chapters 12, 43, 59
FOREWORD
Although the practice of anesthesia professionals and others A particular strength of this book is the numerous descrip
who do airway management is full of unexpected challenges, tions of airway management alternatives and their pros and
perhaps nothing strikes more fear in our hearts than a patient cons in a wide variety of specific clinical situations. This is based
with a difficult airway. Unlike other events, which may be on the concept-described in its own chapter-of context
limited to certain narrow sub-specialties, challenging airway sensitive airway management; this ties in very strongly with
management occurs across nearly all domains of patient care, human factors and algorithms because every situation is indeed
all patient ages, and many sites of care such as perioperative, different. The approach of high-reliability organizations is to
emergency department, ward settings, as well as in unusual sites standardize where possible, but to remain flexible and resilient
such as pre-hospital or combat casualty care. Hence, books such as circumstances demand. Even for readers who do not usually
as this are vital as contextual compilations of up-to-date infor work in some of the settings described, the well-articulated syn
mation on approaches and techniques for the myriad needs of thesis of the processes of airway assessment, evaluation of the
patients for oxygenation and ventilation. Most simply put, the overall situation, and choice of options will help everyone to
most fundamental goal of airway management is to accomplish hone their decision-making skills whatever their usual setting.
what for most patients is routine, but for some is so elusive, In fact, these case discussions are a simple form of "simula
which is-as one of my supervising attending and later faculty tion" by storytelling-as clinicians hear or read of a colleague's
colleague (Mervyn Maze) put it years ago, to "get some green tough case, they simulate in their own heads what they would
gas in the right hole [U.S . oxygen color code is green] ." This think or do in a similar situation. Such case studies thus natu
spirit is exemplified in the modern evolution from the notion of rally dovetail with the chapter on the use of simulation to teach,
"can't intubate, can't ventilate" to "can't intubate, can't oxygen practice, and hone skills of airway management-with simula
ate" emphasizing that oxygenation comes first with ventilation tion techniques ranging from simple procedural task trainers
as important, but still secondary. to full-blown interprofessional mannequin-based simulations.
As noted in the Preface, the third edition of this book con This book has already stood the test of time, but the third
tains some important new information and new chapters. I edition offers a fully modern view of the complexities and
am particularly pleased by the addition of a chapter on human nuances of this life-threatening and life-saving arena of clini
factors and airway management. Over the last few decades we cal care. The authors, contributors, and I share the hope that
have collectively recognized that all the clinical knowledge or through the knowledge, skills, attitudes, and behaviors con
technical dexterity in the world can come to no avail with veyed by this book the rightful fear of the difficult airway will
out appropriate design and use of equipment, systems, pro be surmounted by mastery and expertise, leading to the preser
cesses, and teamwork. Another key tenet of human factors is vation or rescue of uncounted hearts, brains, and lives.
the importance of cognitive scientist Don Norman's concept of
putting "knowledge in the world" rather than just relying on David M. Gaba, MD
"knowledge in the head." The creation of a variety of standard Associate Dean for Immersive & Simulation-based Learning
protocols for airway management, and their representation in Professor of Anesthesiology, Perioperative & Pain Medicine
various graphical cognitive aids, is now a well-accepted and Stanford School of Medicine
critical aspect of modern airway management preparation and Staff Physician and Founder & Co-Director,
execution. Thus, the chapter on the algorithms that describes Patient Simulation Center
and compares the many different protocols, mnemonics, and VA Palo Alto Health Care System
graphics is particularly useful. No one protocol will suit all cli Palo Alto, California
nicians and all sites so knowing their individual strengths and
weaknesses is important.
xix
PREFACE
Since the last edition of our textbook, strategies and guidelines emphasized the importance of early front of neck access using
in managing the difficult and failed airway from the American open cricothyrotomy in the adult population.
Society of Anesthesiologists, the Canadian Airway Focus This edition is divided into ten sections: the first section
Group, the Difficult Airway Society in the United Kingdom, consists of the foundational information in airway manage
and other organizations have been updated and revised using ment; the second section reviews airway devices and techniques;
the currently available evidence. These revised recommenda the third to the ninth sections discuss airway management in
tions for the management of the difficult and failed airway are different clinical settings, including prehospital care, in the
reflected in all chapters of this edition of the textbook includ Emergency Department, the Intensive Care Unit, the operat
ing the new chapters. For example, two chapters (Chapters 6 ing room, the Post Anesthetic Care Unit, as well as other parts
and 34) were added to this edition to address "human factors" of the hospital; and the last section highlights practical issues
as they relate to the stresses and strains of difficult and failed in airway management. A number of new chapters and clinical
airway management. The Difficult Airway Society guidelines cases have been added to this new edition. As indicated above,
specifically acknowledge the importance of human factors in two chapters have been added to discuss human factors in air
crisis resource management. Interpreted in context, the appli way management. To avoid confusion related to "front of neck"
cation of the four basic methods of oxygenation (bag-mask access, a tracheotomy chapter has been added to this edition.
ventilation, use of extraglottic devices, tracheal intubation, In addition, chapters discussing the management of patients
and front of neck access) remains the most logical approach with the aspiration of gastric contents, obstructive sleep apnea,
for managing a failed airway. Furthermore, the National Audit tracheal stenosis requiring jet-ventilation, and airway manage
Project 4 (NAP4) and other studies have consistently identified ment under combat conditions have been added to this edition.
difficulties associated with needle (Seldinger technique) crico Videos depicting all airway management techniques are
thyrotomy such that it has become clear that when faced with a available at http://DifficultAirwayVideos.com. Bag mask
"cannot intubate, cannot oxygenate" (CICO) situation, surgical ventilation, topical anesthesia of the upper airway, and open
(open) cricothyrotomies are much more successful than needle cricothyrotomy videos have been added to this edition.
or Seldinger cricothyrotomies. Many chapters of this edition
xxi
ACKNOWLEDGMEN TS
We would like to thank all the contributing authors for making assistance, Christopher Hung and David Hung for the production
this book possible. In addition, we would like to thank all the of the images and videos. We also like to thank all of the McGraw
associate editors (with rwo additional associate editors) for their Hill editorial and production staff for rheir continuing support.
tireless efforts to ensure that the information in this book is clear Orlando Hung, MD, FRCP(C)
and accurate. We wish to thank Sara Whynot for her editorial Michael F. Murphy, MD, FRCP(C)
xxi i i
2
CHAPTER 1
Evaluation of the Airway

Michael F. Murphy and Johannes M. Huitink
INTRODUCTION.................................. 2 complications in the operating oom (OR), critical care units, and
emergency dep� nts leading to death, brain damage, emergency
INCIDENCE OF DIFFICULT AND FAILED AIRWAY.. 3 surgical airway,<or\mexpected ICU admission.5•6 NAP4 reinforced
STANDARD OF CARE. .................... 4
the findings 0f.the ational Reporting and Learning System in the
United Kingdom �hat found 18% of 1085 airway management
DEVELOPMENT OF DIRECT complications in ICU over a 2-year period (2005 to 2007) were
LARYNGOSCOPIC INTUBATION . 5 directly related to the act of intubation.7
t is critically important to recognize that the single most
DEFINITIONS OF DIFFICULT AND FAILED AIRWAYS ..
important factor leading to a failed airway is the failure to predict
PREDICTION OF DIFFICULT AND FAILED AIRWAY ...... 9 d-ie aifficult airway.3.4 ,s Other factors that can make airway man
agement challenging are human factors as described in Chapter 6.
SUMMARY ....... Screening tests intended to predict difficult or impossible BMV
and laryngoscopic intubation are unable to predict success or
SELF-EVALUATION QUESTIONS.
failure with any degree of certainty in otherwise normal patients.
For this reason, the terms "reassuring" and "non-reassuring" have
been coined to describe one's summative assessment of the vari
ous operations associated with airway management (e.g., BMV,
EGO, laryngoscopy and intubation, and surgical airway).9 It is
because of this "reliability gap" that airway practitioners need to
INTRODUCTION be prepared to manage an airway predicted to be difficult appro
priately (e.g., awake technique) and to resort to surgical airway
''Airway management" may be defined as the application of ther management in the event that nonsurgical techniques faiJ.9·11
apeutic interventions that are intended to effect gas exchange in The fundamental dilemma facing the airway practitioner is to
patients who are unable to do it for themselves. Gas exchange predict if the airway is "reassuring" or "non-reassuring." The task
is fundamental to this definition.1 A number of devices and is to identify non-challenging versus challenging airways employ
techniques are commonly employed in health care settings to ing tools with poor predictive value alone and in combination. As
achieve this goal. These include the use of bag-mask-ventilation mentioned above, theASA Guidelines have used the terms "reassur
(BMV), extraglottic devices (EGOs), oral or nasal endotracheal ing" and "non-reassuring." Huitink and Bouwman12 have recently
intubation (ETI), and invasive or surgical airway techniques. advanced the proposition that a trained practitioner should be able
The failure to adequately manage the airway has been identified to manage a patient with a reassuring airway (they use the term
as a major factor leading to poor outcomes in anesthesia, critical care, "basic airway") employing basic airway management techniques
emergency medicine, hospital medicine, and emergency medical (BMV and ETI) after proper training. Even more advanced airway
services (EMS).2·3 Adverse respiratory events constituted the largest rescue techniques (e.g., EGO) in these patients are expected to be
single cause of injury in the ASA Closed Claims Project.4 The 4th relatively easy because the anatomy is normal. Conversely, they
National Audit Project (NAP4) conducted in the United Kingdom maintain that the less reassuring the airway, the greater the need to
over a 1-year period of time identified major airway management prepare for failure. A very common sense approach!
Eva l u ation of t h e Ai rway 3
This chapter deals with the identification of the difficult and life-threatening if gas exchange cannot be provided expeditiously
failed airway, particularly in an emergency, in which case evalu and adequately by other means. Furthermore, the alternative air
ation and management must be done concurrently in a com way technique employed must have the highest degree of success
pressed time frame and canceling the case or delaying airway in the practitioner's skill set. It is inappropriate to make random
management is not an option. disorganized attempts to manage the airway in the hope that one
Successful airway management is generally governed by four of the airway techniques might work. Rather, one should have
interrwined factors that constitute the "context" in which that a planned strategy (see the algorithms in Chapter 2) including
airway is managed (see Chapter 7) : invasive techniques such as cricothyrotomy. 1 1•16•17
• A clinical situation of varying urgency, venue, and resources
Caveat:
• Patient factors including airway anatomy and vital organ
system reserve
Failure to Evaluate the Airway and Predict Difficulty is the
• Available airway resources
Single Most Important Factor Leading to a Failed Airway.
• Skills of the airway practitioner
(ASA Closed Claims Database)4
Because the airway practitioner must choose a method of airway
management from an array of techniques, precision of language This assumes that the practitioner acts on the prediction and
and communication is essential. Success or failure to effect gas selects the most appropriate technique.
exchange in an apneic patient may occur with any single method:
• Bag-mask-ventilation I NC I D E NCE OF D I F F I C U LT A N D
• Extraglottic device ventilation FAI LED AI RWAY
• Direct laryngoscopy or DL (e.g., straight or curved laryngo
scope blades) • How Common Are the Difficult and
• Indirect laryngoscopy (e.g. , video-laryngoscopy [VL] , flexible Failed Airway?
endoscopy) Bag-mask-ventilation, the use of EGDs, ETI, and surgical air
• Emergency oxygenation and ventilation techniques (e.g. , way management constitute the four primary avenues by which
Ventrain'M or Manujet'M) gas exchange is provided in the event patients are unable to do
• Invasive surgical airway (e.g., cricothyrotomy) so adequately for themselves. In each category, difficulty and
Airway practitioner may find any of these methods "diffi failure may be encountered. Failure of all four, ordinarily, leads
cult," and difficulty with one does not necessarily indicate that to death or brain damage.
another will be difficult though there tends to be a relation Until recently, the success or failure of airway management
ship. 13' 14 Strategies to identifY difficult BMV, difficult ventila has been defined in terms of BMV and orotracheal intuba
tion employing an LMA, difficult DL and intubation, difficult tion. The introduction of EGDs and the heightened profile of
VL, and difficult surgical airway will identifY predictors unique cricothyrotomy have broadened such concepts. Fortunately, tra
to the method (e.g., surgical airway would be difficult in a cheal intubation is usually straightforward, particularly in the elec
patient with an anterior neck hematoma or tumor mass) , and tive setting of the OR, though it should be realized that tracheal
predictors associated with some of the other methods (e.g., intubation can be performed in many different ways with direct or
male sex) or all of the other methods (e.g. , history of neck and indirect techniques and each technique has its own complication
upper airway radiation therapy or the application of cricoid and failure rates. The same cannot be said for venues outside of
pressure) . This expands on the definition of difficult as pro the OR where airways are often anything but "straightforward."
mulgated by the American Society of Anesthesiologists (ASA) Airways that are difficult to manage are fairly common in anes
beyond difficult BMV and intubation to include the complete thesia, emergency medicine, critical care, and EMS practice, with
array of methods that may be employed to manage an airway. 10 some estimates as high as 20% of all emergency intubations.9-1 2•18-2 1
Any method may fail in which case the terminology "failed However, the incidence of intubation failure is quite uncommon
BMY," "failed ETI," or "failed EGD" may be employed. (ranging 0.5% to 2.5%), and the disastrous situation of being
Conventionally, if all of these methods fail the airway is called unable to intubate or ventilate rarely occurs (0. 1 o/o to 0.05%) . 2•18-26
a "failed airway," and is equated with a "cannot intubate, can This translates to a "can't intubate, can't oxygenate" failure rate of
not oxygenate" (CICO) airway. 1 1 In the past, this situation has about 1 : 1 000 to 1 :2000 patients in a general surgical population.
been called "cannot intubate, cannot ventilate" (CICV) , though The incidence is strikingly higher in the parturient undergoing
CI CO is more accurate and currently more commonly employed. cesarean section (1 :280), an almost tenfold increase. 27-29 Further,
For more clarity, a failed intubation defined narrowly as the the gold standard awake flexible bronchoscopic intubation also has
failure to intubate the trachea on three attempts9·15 (the DAS a defined failure rate as high as 1 3%.30
20 1 5 Guidelines permit one additional attempt by an expert:
3+ 1) 1 1 may not constitute a failed airway if one is able to affect • How Do We Avoid Airway Management
gas exchange with BMV or with an EGD. However, intubation Failu re?
failure ought to conjure a sense of urgency and mandates the Although circumstances can vary widely, the expectation is the
airway practitioner to rapidly switch to a failed airway manage same: timely, effective airway management executed without
ment sequence or drill because such a situation may become patient injury. In circumstances of multiple trauma, facial or
4 Pri n c i p l es of Ai rway M a n a g e m e n t
airway swelling, abnormal upper airway anatomy, upper airway Medical) and the EasyTube. Lighted stylet methods may per
hemorrhage, or a myriad of other difficult airway scenarios, mit light-guided (transillumination) intubation in situations
intubation may be difficult, or even impossible, and even BMV in which the vocal cords cannot be visualized, but in the era
can fail. Many other "contextual" factors can make airway man of vision guided intubation aids, there is a decrease in use of
agement challenging such as location, human factors, available this device. With the realization that airway rescue techniques
resources, and experience of the medical team. Nevertheless, should be done quickly, the so called "one second intubation
the goal remains that the patient's airway be promptly secured technique" employing disposable camera tube devices (ET
and oxygenation be maintained. VIEW Vivasight•) are gaining popularity when used in combi
Responding to an identified need to reduce the incidence nation with an EGO such as the iGel or Air-Q. Certain airways
of airway management failure, the American Society of are impossible to manage by any means other than cricothy
Anesthesiologists (ASA) issued guidelines and an algorithm for rotomy, a procedure that all airway practitioners ought to be
management of the difficult airway in 1 993, with subsequent competent to perform. Several techniques have been advocated,
revisions in 2003 and 20 1 3 .9'10'31 The guidelines stressed the including the "no drop" cricothyrotomy and the "fast surgical
importance of performing an airway evaluation for difficulty airway'' technique, a 4-step bougie-scalpel-tube technique1 1•33
prior to inducing anesthesia and paralyzing the patient. (see Chapter 1 4) .
Planned awake intubation, awakening the patient in the pres The challenge for any airway practitioner i s to b e able to
ence of a failed airway, and acquiring skills in alternative airway accurately predict when a difficult airway is present, to imme
management techniques are hallmarks of the 1 993 guidelines. diately recognize when an intubation failure has occurred, and
The 2003 guidelines reemphasize the importance of the airway to reliably and reproducibly ensure continuous gas exchange in
evaluation and incorporate the laryngeal mask airway (LMA) both of these unnerving circumstances.
as a discrete step in the algorithm, should failure occur. In the
20 1 3 guidelines VL is incorporated as a first airway manage
ment plan. The DAS have come up with simplified guidelines STA N DARD OF CARE
for management of the unanticipated difficult intubation in
adults in 20 1 5 emphasizing emergency oxygenation and ven • Is There a Prevailing Standard of Care in
tilation techniques. 1 1 Managing the Difficult and Fa iled Ai rway?
Unfortunately, the ASA and DAS guidelines are less use How Is It Defined?
ful outside the OR, especially in circumstances in which tra The growth in knowledge and evidence related to the practice
cheal intubation must be accomplished quickly and awakening of airway management is relentless. Advances in airway man
the patient is not an option. Even in the OR setting, explicit agement over the past two decades have significantly improved
guidelines for the rapid evaluation of an airway for occult dif patient outcome with a reduction in the incidence of death and
ficulty and the prioritization of rescue maneuvers in the event disability.34 1he challenge for the practitioner is to keep abreast
of a mandated immediate intubation are not well handled by of new information and new techniques to practice within the
the ASA or DAS guidelines and algorithms (see Chapter 2) . standard of care.
Furthermore, these guidelines do not take into consideration Black's Law Dictionar/ 5 defines the "standard of care" as:
patients who are uncooperative (e.g. , young children or men
The average degree of skill, care and diligence exercised by
tally challenged patients) or different patient populations (e.g. ,
members of the same profession, practicing in the same
pediatrics and near term parturients [see Chapter 5 1 ] ) .
or similar locality in light of the present state of medical
Further complicating this issue are the many new, effective,
and surgical science.
and safe airway devices that have been introduced to assist with
difficult and failed airway management. Flexible endoscopic This definition incorporates several important features:
and video-intubating bronchoscopes have become more por
• Average degree of skill
table and easier to use and have been joined by a collection of
• Same or similar locality
rigid optical devices and stylets (e.g. , Shikani Optical Stylet'",
• Present state of knowledge
Bonfils Stylet'", Levitan FPS Scope'", Clams Optical Stylet'",
etc.) , hybrid devices employing cameras or fiberoptics, such Taking these into consideration, the standard of care is the
as video-laryngoscopes (e.g. , GlideScope•, McGrath• Series 5 conduct and skill of an average and prudent practitioner that
video-laryngoscope, McGrath• MAC, King Vision•, AirTraq•, can be expected by a reasonable patient. A bad result due to a
Storz CMAc•, see Chapter 1 1 ) , and disposable camera tubes failure to meet the standard of care is generally considered to
(Vivasight, ET View Medical) . be malpractice. There are two main sources of information as
The LMA and intubating laryngeal mask airway (ILMA or to exactly what is the expected standard of care:
LMA Fastrach'") have assumed a distinct role in the manage
• The beliefs and opinions of experts in the field.
ment of both the difficult and the failed airway. In the pre
• The published scientific evidence, standards of care, practice
hospital setting the iGel (lntersurgical) and Air-Q (CookGas)
guidelines, protocols.
have assumed a more prominent role for initial airway man
agement, and rescue during rescucitation.3 2 The Combitube'" Driven by the complex nature of this clinical dilemma and
had been used in the past as a lifesaving rescue device, though the need for successful solutions that are easily learned and
now largely replaced by the King Laryngeal Tube airway (Ambu maintained (and cost-effective) , the standard of care in airway
Another random document with
no related content on Scribd:
If we sight(14) naught but seas at dawn?”
“Why, you shall say, at break of day,(15)
Sail on! Sail on! Sail on and on!”
They sailed.(16) They sailed.(17) Then spake(18) the mate:

“This mad sea(19) shows his teeth to-night,
He curls his lip, he lies in wait
With lifted teeth,(20) as if to bite!
Brave Adm’r’l,(21) say but one good word;
What shall we(22) do when hope is gone?”
The words leapt like a leaping sword:(23)
“Sail on! Sail on! Sail on! and on!”
Then pale and worn,(24) he paced his deck

And peered through darkness. Ah, that night(25)
Of all dark nights! And then a(26) speck—
A light!(27) A light? A light! A light!
It grew,(28) a starlit flag unfurled!
It grew to be Time’s burst of dawn.(29)
He gained a world,(30) he gave that world
Its grandest less’n: “On! Sail on!”
A Suggestive Outline for the Study of a Selection
I. Mastery of Main Theme

The first step in the study of any selection is to gain an idea of it as
a whole. This can best be done by reading the selection in its
entirety. If there should be strange words, let them pass for the time
being. Thus we grasp the predominant mood and significant setting
or situation.
II. Progressive Analysis

Read the selection, silently, a second time. The aim now is to
make a mental note of the several parts which make up the whole.
This demands close concentration, in order that we may unify
matters and prevent abrupt transitions. We are to break up the whole
into parts, and each part represents a thought group.
1. Punctuation makes the meaning clear, and the clear meaning
determines the various groups. Example: “It came, rushing in
torrents like an avalanche of rock.” We do not pause after “came,”
although it is so punctuated. Question: Do you find like instances in
the selection under consideration? Where?
2. The length and frequency of the pause which sets off the
groups is dependent upon the context and upon the listeners. If the
context is serious, or if the listeners are uneducated, there will of
necessity be many groups. And obversely, if the context is not
serious or difficult, or if the audience is educated, there will be fewer
and longer groups.
Question: What is the situation in the present selection?
3. In the study of the chief word in the group we must remember
that its real meaning depends upon its relation to the other words in
the same group. For instance, the word “fire” does not mean the
same thing at all times. The meaning of this word depends upon its
kinship with other members of the same group. When we say, “The
house is on fire,” this word “fire” means an altogether different thing
than when we say, “There is a fire in the stove this morning.” Let us
take care that we do not isolate words, but that we get their
associative meanings.
Questions: What are the important words in the various groups?
What is the real meaning of each? Why? Give five synonyms of
each.
III. Reference to Experience

We are now prepared to call upon our storehouse of past
experiences in order that we may identify ourselves more closely
with the author’s meaning. We are to react upon what we read. The
more vividly we can bring what we read from the page into our own
actual experience, the more deeply are we impressed with its
meaning. We translate the unseen, the unfelt and unbelieved by
likening it to what is already seen, felt or believed. If experience is
lacking, we draw upon our imagination.
1. If we are reading a description, we will see this scene in

terms of a past like experience.
2. If we are reading a narration, we will feel it in terms of a
past like experience.
3. If we are reading something we have not believed, we will
accept it in terms of what we have already believed.
Question: What experiences does this selection call upon from

me? What purposes do they serve?
IV. Classification
There are three divisions into which all selections may be put. A
selection may be written to make something Clear; it may be for the
purpose of inspiring, or elevating one’s thoughts and feelings—to
make Impressive; it may be for the purpose of enforcing some great
truth—to make Belief. This classification is based upon the author’s
purpose.
Questions: Where the author’s purpose is to make Clear some
obscure point or idea.
1. What significant words are used?

2. Is there any obscurity? Why?
3. What illustrations or comparisons are made?
4. Think earnestly of an experience which will aid you to see
clearly the author’s purpose.
Where the author’s purpose is Impressiveness

1. Is the emotion aroused pleasurable?
2. Have you had an experience which resembles what is
referred to?
3. What mood is predominant? Is it:
Impassioned, grave, sad,

Triumphant, exalted, solemn,
Humorous, satirical, pathetic,
Inspiring, enheartening, discouraging?
4. What are the minor moods? Supply your own descriptive

mood if none of the following are adequate:
Fanciful, enthusiastic, cheerful,

Dreamy, sentimental, witty,
Pensive, tender, serene, quiet,—or suggestive of
Awe, loneliness,
Admiration, suspense, joy, anger,
Fear, rage, sympathy, grief, sorrow, surprise, anxiety.
Where the author’s purpose is Belief. The author does more than
make us see, or feel.
1. What actual experience have you had that resembles the

thing the author would have you believe?
2. Do you accept as truth what you have read?
3. What particular thought carries the most conviction?
4. Do you think others should believe what the author says?
5. Is it clear and impressive, and do you believe it?
V. Setting
This has to do with time, place, objects, sounds, movement, or
anything that gives local color to the selection.
Questions:
1. Is it modern or old?
2. Where is the scene laid?
3. Are descriptions given in detail or mere suggestion?
4. Is dialect used?
5. Will personation aid in rendering the selection?
6. Does the power and beauty of the selection lie in narration,
description, or in character drawing?
7. Name some definite things, sounds or objects described,
that give color or atmosphere.
8. Is the movement:
Slow, swift, light, heavy,

Tripping, graceful, spirited,
Powerful, easy, varied?
VI. Vocalization
Let our guide be as Shakespeare has so well put it:
Let your own discretion be your tutor. Suit the action to the word;
the word to the action; with this special observance—that you
o’erstep not the modesty of nature.
1. Read the selection as ordinary conversation.

2. Now read again as enlarged conversation, or, as it were,
for the ears of many.
3. Ask yourself the following questions:
(1) Do I make proper use of Pitch?

(2) Do I make proper use of Pause?
(3) Do I make proper use of Inflection?
(4) Do I make proper use of Tone Color?
(5) Do I make proper use of Stress?
(6) Do I make proper use of Movement?
4. At all times let us remember that our purpose is not to give

a pleasing performance, but faithfully to interpret the
author’s meaning.
A Condensed Outline for the Study of a Selection for

Oral Presentation
I. Intelligent Impression
A. General Preparation
Read silently the entire selection. The purpose is to gain an
impression of the selection as a whole.
1. What was the author’s purpose in writing this selection?

2. What specific intent did he have:
a. To make something clear?

b. To make something impressive?
c. To establish a truth?
d. To stimulate to righteous action?
3. Consult the dictionary for the meaning of strange words.

4. Look up the historical references.
B. Special Preparation
Read the selection silently a second time. The aim is to make a
mental note of the respective importance of the several parts which
make up the whole.
1. What is the definite idea, or definite picture, or definite

feeling the author would have us get?
2. In what part of the selection is the author’s aim most
forcibly presented?
3. What is the relative value of the thought-groups?
II. Intelligible Expression
A. General Preparation
Before rendering a selection orally it must be given a setting. This
has to do with time, place, objects, sounds, movements, or anything
that tends to give local color.
1. Is the selection colloquial or dramatic?

2. Is dialect used?
3. Will personation be necessary?
4. Give an original word-picture of the characters and
situation.
5. To what reference to experience does it make?
6. What is the predominant mood?
B. Special Preparation
Read the selection aloud for the first time. In doing this, ask
yourself:
1. Am I reading with correct thought-groups?

2. Do I make proper use of the pause? (Remember the length
and frequency of the pause depends upon the nature of
the subject and the audience.)
3. Am I enunciating clearly?
4. Is my voice melodious? That is, do I make proper use of
pitch and inflection?
5. Am I conscious of the change and interchange of moods?
6. Do I make proper use of stress and movement?
7. Do my tones fit the color-words?
8. Am I faithfully and adequately interpreting the author’s
meaning?
PROSE SELECTIONS
Humorous
Pathetic
Dramatic
Dialect
THE JOY OF READING

Who can estimate the joy, comfort and inspiration reading has
afforded to the human race, how many weary hours it has solaced,
how many distracted minds it has quieted, how many harassed souls
it has soothed into forgetfulness? Who has not felt the thrill of
discovery when he has found a new author, a new poet who
peculiarly affected his mind, his soul, his risibilities, his ambitions, his
life? I shall never forget when I found Charles Warren Stoddard’s
“Apostrophe to a Skylark.” It was buried in one of his books and few
seemed ever to have read it. There was joy incalculable in putting it
side by side with Shelley’s classic “Ode” and comparing the two
conceptions. Thousands of souls have been inspired by reading to
higher, nobler, more worthy endeavor. So, like Sancho Panza, we
bless God and thank Him for the man who invented reading.
—George Wharton James.
HUMOROUS SELECTIONS
NATHAN FOSTER
By Paul L. Dunbar
Nathan Foster and his lifelong friend and neighbor, Silas
Bollender, sat together side by side upon the line-fence that
separated their respective domains. They were both whittling away
industriously, and there had been a long silence between them.
Nathan broke it, saying:
“’Pears to me like I’ve had oncommon good luck this year.”
“Wall, you have had good luck, there ain’t no denyin’ that. It ’pears
as though you’ve been ee-specially blest.”
“An’ I know I ain’t done nothin’ to deserve it.”
“No, o’ course not. Don’t take no credit to yourself, Nathan. We
don’t none of us deserve our blessings, however we may feel about
our crosses; we kin be purty shore o’ that.”
“Now, look, my pertater vines was like little trees, an’ nary a bug
on ’em.”
“An’ you had as good a crop of corn as I’ve ever seen raised in
this part of Montgomery county.”
“Yes, an’ I sold it, too, jest before that big drop in the price.”
“After givin’ away all yer turnips you could, you had to feed ’em to
the hogs.”
“My fruit trees jest had to be propped up, an’ I’ve got enough
perserves in my cellar to last two or three winters, even takin’ into
consideration the drain o’ church socials an’ o’ charity.”
“Yore chickens are fat and sassy, not a sign o’ pip on ’em.”
“Look at them cows in the fur pastur. Did yer ever see anything to
beat ’em fer sleekness?”
“Wall, look at the pasture itself; it’s most enough to make human
beings envy the critters. You didn’t have a drop of rain on yer while
you was gettin’ in yer hay, did yer?”
“Not a drop.”
“An’ I had a whole lot ruined jest as I was about to rick it.”
“Silas, sich luck as I’m a-havin’ is achilly skeery; it don’t seem
right.”
“No, it don’t seem right for a religious man like you, Nathan. Ef you
was a hard an’ graspin’ Sinner, it ’ud be jest makin’ you top-heavy
so’s yore fall ’ud be the greater.”
“I don’t know but what that’s it, anyhow. Mebbe I’m a-gettin’ puffed
up over my goods without exactly knowin’ it.”
“Mebbe so, mebbe so. Them kind o’ feelin’s is mighty sneakin’
comin’ on a body. O’ course I ain’t seen no signs of it in you; but it
’pears to me you’ll have to mortify yore flesh yit to keep from being
purse-proud.”
“Mortify the flesh?”
“O’ course, you can’t put peas in yore shoes er get any of yer
frien’s to lash you, so you’ll have to find some other way of mortifyin’
yer flesh. Wall, fer my part, I don’t need to look fur none, fur I never
had too many blessin’s in my life, less’n you’d want to put the
children under that head.”
Silas shut his jack-knife with a snap and, laughing, slid down on
his side of the fence. In serious silence Nathan Foster watched him
go stumping up the path toward the house.
“Silas seems to take everything so light in this world; I wonder how
he can do it.”
With Nathan, now, it was just the other way. Throughout his eight
and forty years he had taken every fact of life with ponderous
seriousness. Entirely devoid of humor, he was a firm believer in
signs, omens, tokens, and judgments. He was a religious man, and
his wealth frightened and oppressed him. He gave to his church and
gave freely.
As usual, he had taken his friend’s bantering words in hard
earnest and was turning them over in his mind.
The next morning when Nathan and Silas met to compare notes,
Nathan began:
“I have been thinking over what you said last night, Silas, about
me mortifyin’ my flesh, and it seems to me like a good idee. I
wrasselled in prayer last night, and it was shown to me that it wa’n’t
no more’n right fur me to make some kind o’ sacrifice fur the mercies
that’s been bestowed upon me.”
“Wall, I don’t know, Nathan; burnt-offerings are a little out now.”
“I don’t mean nothin’ like that; I mean some sacrifice of myself,
some—”
His sentence was broken in upon by a shrill voice that called from
Silas Bollender’s kitchen door:
“Si, you’d better be a-gittin’ about yore work instid o’ standin’ over
there a-gassin’ all the mornin’. I’m shore I don’t have no time to
stand around.”
“All right, Mollie; speakin’ of mortifyin’ the flesh an’ makin’ a
sacrifice of yoreself, Nathan, why don’t you git married?”
Nathan started.
“Then you’d be shore to accomplish both. Fur pure mortification of
the flesh, I don’t know of nothin’ more thoroughgoin’ er effectiver
than a wife. Also she is a vexation to a man’s sperit. You raaly ought
to git married, Nathan.”
“Do you think so?”
“It looks to me that that ’ud be about as good a sacrifice as you
could make; an’ then it’s such a lastin’ one.”
“I don’t believe you realize what you air a-sayin’, Silas. It’s a
mighty desprit step that you’re advisin’ me to take.”
Again Mrs. Bollender’s voice broke in:
“Si, air you goin’ to git anything done this mornin’, er air you goin’
to stand there an’ hold up that fence fur the rest of the day?”
“Nathan, kin you stand here an’ listen to a voice an’ a speech like
that an’ then ask me if I realize the despritness of marriage?”
“It’s desprit, but who’d you advise me to marry,—Silas, that is, if I
made up my mind to marry,—an’ I don’t jest see any other way.”
“Oh, I ain’t pickin’ out wives fur anybody, but it seems to me that
you might be doin’ a good turn by marryin’ the Widder Young. The
Lord ’ud have two special reasons fur blessin’ you then; fur you’d be
mortifyin’ yore flesh an’ at the same time a-helpin’ the widder an’ her
orphans.”
“That’s so.” He couldn’t admit to Silas that he had been thinking
hard of the Widow Young even before he had of mortifying his flesh
with a wife.
Once decided, it did not take him long to put his plans into
execution. But he called Silas over to the fence that evening after he
had dressed to pay a visit to the widow.
“Wall, Silas, I’ve determined to take the step you advised.”
“Humph, you made your mind up in a hurry, Nathan.”
“I don’t know as it’s any use a-waiting; ef a thing’s to be done, I
think it ought to be done and got through with. What I want particular
to know now is, whether it wouldn’t be best to tell Lizzie—I mean the
widder—that I want her as a means of mortification.”
“Wall, no, Nathan, I don’t know as I would do that jest yit; I don’t
believe it would be best.”
“But if she don’t know, wouldn’t it be obtainin’ her under false
pretenses if she said yes?”
“Not exactaly the way I look at it, fur you’ve got more motives fur
marryin’ than one.”
“What! Explain yoreself, Silas; explain yoreself.”
“I mean you want to do her good as well as subdue your own
sperit.”
“Oh, yes, that’s so.”
“Now, no woman wants to know at first that she’s a vexation to a
man’s sperit. It sounds scriptual, but it don’t sound nooptial. Now
look at me an’ Mis’ Bollender. I never told her until we’d been
married more’n six months; but she didn’t believe it then, an’ she
won’t believe it till this day.”
“Wall, I’ll agree not to tell her right away, but if she consents, I
must tell her a week or so after we are married. It’ll ease my
conscience. Ef I could tell her now, it ’ud be a heap easier in gittin’
round the question. I don’t know jest how to do it without.”
“Oh, you won’t have no trouble in makin’ her understand.
Matrimony’s a subject that women air mighty keen on. They can see
if a man’s a-poppin’ the question ef he only half tries. You’ll git
through all right.”
Somewhat strengthened, Nathan left his friend and sought the
widow’s home. He found her stitching away merrily under the light of
a coal-oil lamp with a red shade.
“La, Nathan, who’d a’ expected to see you up here? You’ve got to
be such a home body that no one don’t look to see you out of yore
own field and garden.”
“I jest thought I’d drop in.”
“Wall, it’s precious kind of you, I’m shore. I was a-feelin’ kind o’
lonesome. The children go to bed with the chickens.”
“I jest thought I’d drop in.”
“Wall, it does remind me of old times to see you jest droppin’ in,
informal like, this way. My, how time does fly!”
“Widder, I’ve been thinkin’ a good deal lately; I’ve been greatly
prospered in my day; in fact, my cup runneth over.”
“You have been prospered, Nathan.”
“Seems ’s ef—seems ’s ef I ought to sheer it with somebody, don’t
it?”
“Wall, Nathan, I don’t know nobody that’s more generous in givin’
to the pore than you air.”
“I don’t mean in jest exactly that way. I mean, widder—you’re the
morti—I mean the salvation of my soul. Could you—would you—er
do you think you’d keer to sheer my blessin’s with me an’ add
another one to ’em?”
The Widow Young looked at him in astonishment; then the tears
filled her eyes as she asked, “Nathan, do you mean it?”
“I wouldn’t a-spent so much trouble on a joke, widder.”
“No, it don’t seem that you would, Nathan. Well, it’s mighty
sudden, mighty sudden, but I can’t say no.”
“Fur these an’ many other blessin’s make us truly thankful, O
Lord,” said Nathan devoutly. And he sat another hour with the widow
making plans for the early marriage, on which he insisted.
The widow had been settled in Nathan’s home over a month
before he had ever thought of telling her of the real motive of his
marriage, and every day from the time it occurred to him it grew
harder for him to do it.
One night when he had been particularly troubled he sought his
friend and counselor with a clouded brow. They sat together in their
accustomed place on the fence.
“I’m bothered, Silas.”
“What’s the matter?”
“Why, there’s several things. First off, I ain’t never told the widder
that she was a mortification, an’ next she ain’t. I look around at that
old house o’ mine that ain’t been a home since mother used to scour
the hearth, an’ it makes me feel like singin’ fer joy. An’ I hear them
children playin’ round me—they’re the beatenest children; that
youngest one called me daddy yistiddy—well, I see ’em playin’ round
and my eyes air opened, an’ I see that the widder’s jest another
blessin’ added to the rest. It looks to me like I had tried to beat the
Almighty.”
“Wall, now, Nathan, I don’t know that you’ve got any cause to feel
bothered. You’ve done yore duty. If you’ve tried to mortify yore flesh
an’ it refused to mortify, why, that’s all you could do, an’ I believe the
Lord’ll take the will fer the deed an’ credit you accordin’ly.”
“Mebbe so, Silas, mebbe so.”
—Copyright by Dodd, Mead & Co., New York, and used by
arrangement.
DOING A WOMAN’S WORK

By McKillip-Stanwood
“Breakfast ready yet?” asked Jack Telfer, as he set two pails of
foaming milk on the bench and turned to wash his hands.
“Almost,” replied his wife. “But, say, Jack, won’t you fix the calf pen
while you’re waiting? It won’t take but a minute. The calves got out
twice yesterday and tramped all over the flower beds and garden. I
had an awful time getting them in. I tried to fix it, but I don’t think I did
a good job.”
“I can’t stop now. I guess it’s all right. If they get out, why chase
them in; you have nothing else to do, and I’ll fix it up right when I get
time. I want my breakfast now. I can’t fool around here till noon. I’ve
got to cultivate the peaches to-day.”
“I’ve nothing else to do,” repeated his wife, as she dished up the
tempting breakfast. “Well, I like that, Jack Telfer. I wish to goodness I
hadn’t any more to do than you have.”
“Why, what under the sun have you to do? You have only Toodles
and me to look after and this little house to keep. I could do all the
work you do with one hand tied behind me and then find time to
throw at the birds. You see, I know what I am talking about, for I can
cook and do housework as well as any woman.”
“You’ve never displayed any talent in that direction since I’ve
known you. It’s like pulling teeth to get you to do a chore around the
house. Not that I want a man to do housework, for I don’t; that’s a
woman’s business. But when she has every step to take and a
dozen things to do at once, a little help occasionally comes mighty
handy.”
“Well, the reason I don’t help around here is because there isn’t
much to do. The work you have is a snap, my girl, and a mighty soft
one, too. Why, my mother had nine children and did all her own work
and cooked for harvest hands and threshers and used to help the
neighbors out if they got in a pinch.”
“Well, my dear husband, I do not doubt but your mother was a
very smart woman. She must have been to have raised so promising
a son. But women are not all alike, my dear.”
“Now, your work is a sort of paper-flower work compared with what
I have to do. It would be a picnic for me to stay in the house, wash
dishes, play with the baby and do such things.”
“All right, suppose you have a picnic to-day. I can drive the
cultivator just as well as you and you can cook and keep house a
great deal better than I; at least you think you can. I’ll hitch up and
cultivate the peaches and you can tie one hand behind you and do
the work to-day and see how much time you have to throw at the
birds. What do you say?”
“Say,” laughed Mr. Telfer as he pushed back from the table. “Why, I
say I’m willing, but if you don’t get enough riding in the hot sun—”
“The hot sun,” interrupted his wife, “is no worse than the hot stove
I cook over. Will you do it?”
“You bet I’ll do it, but you must tell me what’s to be done so you
can’t throw it up to me for ever after that the reason I got through so
soon was because I didn’t do half the work.”
“First,” said Mrs. Telfer, “there’s the milk to skim and the calves to
feed and the churning to do. Skim the milk on the north shelf in the
cellar; the dishes to wash, and don’t forget to scald the churn and the
milk things. Then you can iron; the clothes are all dampened down in
the basket. You need not iron any but the plain things, I’ll do the
others. Pit the cherries I picked last night and make a pie for dinner.
And, oh, yes, you will have to kill a chicken and dress it, for you
know you said last night you wanted chicken and dumplings for
dinner to-day, and now is your chance.
“Stew some prunes for supper to-night, make the bed, sweep and
dust and get the vegetables ready for dinner. Oh, I guess you know
about what there is to do. I must be off now, for it is nearly 6 o’clock.”
And she was gone.
“Well, it’s early yet; guess I’ll smoke and read the Rural World
awhile. There’s an article on hogs I wanted to read; it seems nice to
have time to do what you please.”
After he had read a long time he at last knocked the ashes into his
hand and stretched lazily.
He went down cellar and skimmed the milk, then he fed the
calves, laughed at the way his wife had tried to fix the calf pen, went
in and took off the table cloth and piled the dishes and empty milk
things on the table.
“Guess I’ll wash up before I churn. No, I won’t, either. I’ll churn
first; then I’ll clean up all at once. Oh, I’ve got a head on me. I ought
to have been a woman.”
He brought from the cellar a large new pan of thick cream and set
it on the table, then he went to scald the churn, but the fire was out
and the dish water Mrs. Telfer had put on before breakfast was
nearly cold.
“Blame it all, I’ve got to go to the barn for peach pits; not one in the
basket. But I’ll kill the chicken while I’m out there and save an extra
trip. If Jennie would only use some management about her work
she’d have plenty of time.”
The large pit basket was soon filled, but the chicken was another
proposition. Every time he selected one to catch it seemed to know it
was a marked bird and would shy off to the edge of the flock. At last
he had to run one down, and he wrung its neck with a great deal of
satisfaction. As he entered the house the clock struck nine.
“Wheu! Where has the morning gone? I must get a move on me.
Guess I’ll make the pie first so it can bake while the water is
heating.”
He prepared the cherries. Then he made the pie; made it as well
as a woman could. He had pushed the dishes back on the cluttered
table to make room for his bread-board, and just as he had the crust
nicely stamped down around the edge of his pie, with a fork, a
tousled head of yellow curls appeared in the doorway, one chubby
hand holding up a long, white nighty, the other rubbing a sleepy eye.
There was surprise on the baby face at the sight of his father.
Papa meant fun for Toodles, and, running to him, he put up his little
arms, saying, “Papa, high me; high Toodles, papa; high Toodles.”
And his father, dusting the flour from his hands, tossed the baby to
the ceiling again and again while the little fellow screamed with
delight.
In the midst of this jolly frolic the clock announced that it was the
tenth hour of the day.
“Hear that, young man?” said the father. “That means that we must
cut out this racket and get down to business. Your paternal ancestor
is chief cook and general manager to-day and has several little
chores to do yet. We will get Toodles’ breakfast first, then wash and
dress him afterwards so that he won’t get mussed up when he eats.
“Mamma don’t do that way, but we can give mamma a few
pointers on keeping a baby clean, can’t we, Toodles?”
And, putting the child in his high-chair, Mr. Telfer pinned a tea
towel around the little neck for a bib, took a bowl and went to the
cellar for some new milk.
While Toodles was eating breakfast his father washed the prunes
and put them on to stew, set the pie in the oven and started to build
the fire, but he was interrupted by an emphatic voice saying, “Papa,
down; papa, down.”
“All right, young man, I’ll attend to your case directly,” said Jack,
touching a match to the kindling. “Guess I’ll wash and dress you and
have you off my hands.”
And, taking a wash-pan of tepid water, with soap, comb, rag, towel
and Toodles, he went into the sitting-room where it was cool and
pleasant. The baby’s clean clothes were lying upon a chair, where
his mamma had placed them the night before. Then what a time they
had. Toodles would catch the wash rag in his teeth and papa would
shake it and growl till the little mouth would have to let loose to
scream with the agonizing fun.
Then came the tangled curls, and it took a wonderful story about a
doggie that would say “Bow, wow,” and a little horsie that Toodles
could ride and a chicky that went “Peep, peep, peep,” and several
other mental concoctions to keep the baby quiet until the ringlets
were in order.
When the clean coaties were on and two little arms hugged papa
tight, Jack Telfer thought, “Jennie calls this work.”
The clock pounded out eleven strokes.
“Blast that clock; what’s got into it,” thought the man, putting the
child down and hurrying to the kitchen. “I’ve been busy every minute
this morning, and here it is 11 o’clock and not a thing done yet.”
He found the fire had burned out; he had forgotten to put the
peach pits on the kindling when he had stopped to fuss with Toodles.
“Well, I guess I’ll make it all right by noon,” he soliloquized. “This is
a hurry-up order, but I’ll be on time or eat my hat.”
He looked at his pie; it was nearly half baked. He built a roaring
fire, packed the stove with peach pits, pulled the prunes to the front
where they would cook quicker, and was debating in his mind which
he should scald first, the churn or the chicken, when something
rushed by the door.
“Drat those calves; they’re out again.”
Snatching his hat, he hurried after them. It was a merry chase for
the calves if not for Mr. Telfer. They were willing to go in any direction
but the right one, and by the time he got them corralled Jack was
hot, tired and cross.

PDF Hungs Difficult and Failed Airway Management Orlando Hung Ebook Full Chapter

Uploaded by

Copyright:

Available Formats

You might also like

PDF Hungs Difficult and Failed Airway Management Orlando Hung Ebook Full Chapter

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PDF Hungs Difficult and Failed Airway Management Orlando Hung Ebook Full Chapter

Uploaded by

Copyright:

Available Formats

Hung’s Difficult and Failed Airway

Management Orlando Hung

Management of the Difficult Pediatric Airway Narasimhan

Frontier Computing Theory Technologies and Applications

A First Course in Fuzzy Logic 4th Edition Hung T.

Research Methods in English Medium Instruction 1st

Science Education Research and Practices in Taiwan

Angry White People Coming Face to Face with the British

Core Topics in Airway Management Cambridge Medicine

Distributed Computing and Internet Technology 16th

ORLA N DO R. HU N G, B S c ( PHARMACY), M D, FRC P (C)

MICHA EL F. MURPHY, M D, FRC P (C)

eBook conversion by codeMantra

Thomas J . Coonan, M D, F RC P (C) J. Ada m Law, M D, F RC P (C)

Contributors .................................................................................... xiii

Acknowledgments ............................................................................. xxiii

PRINCIPLES OF AIRWAY MANAGEMENT

1. Evaluation of the Airway .... . . . .....

3. Preparation for Awake Intubation .... . . . . 39 6. Human Factors and Airway

7. Context-Sensitive Airway 10. Flexible Bronchoscopic Intubation ... . . .172

1 3. Extraglottic Devices for Ventilation 14. Cricothyrotomy.........................259

PRE-HOSPITAL AIRWAY MANAGEMENT

16. What Is Unique About Airway 19. Airway Management of a Race

17. Airway Management of a Patient with 20. Airway Management of a Morbidly

AIRWAY MANAGEMENT IN THE EMERGENCY ROOM

22. Airway Management in the 26. Airway Management in a Patient

AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT (ICU)

29. Unique Airway Issues in the 32. Management of a Patient Admitted to

30. Management of Extubation of a Patient 3 3. Performing an Elective Percutaneous

AIRWAY MANAGEMENT IN THE OPERATING ROOM

35. Airway Management of an 41. Airway Management in a Patient with

36. Airway Management of a Patient 42. Airway Management of a Patient

AIRWAY MANAGEMENT IN THE PEDIATRIC POPULATION

45. Unique Airway Issues in the 48. Airway Management of a 6-Year-Oid

46. Management of a 12-Year-Oid 49. Cannot Intubate and Cannot

47. Management of a Child with 50. A Neonate with a Difficult Airway

AIRWAY MANAGEMENT IN OBSTETRICS

51. What Is Unique About the Obstetrical 5 4. Airway Management of

AIRWAY MANAGEMENT IN UNIQUE ENVIRONMENT

56. Unique Challenges of Ectopic 59. Airway Management in Austere

PRACTICAL CONSIDERATIONS IN AIRWAY MANAGEMENT

62. Difficult Airway Carts....................646 6 4. Teaching and Simulation for

Mathieu Asselin, MD, FRCP(C) Kerryann B. Broderick, BSN, MD

Edward T. Crosby, MD, FRCP(C) Angelina Guzzo, MD, PhD, FRCP(C)

Johannes M. Huitink, MD, PhD Danae Krahn, BHSc (Hons), MD

Kirk J. MacQuarrie, MD, FRCP(C) Michael F. Murphy MD, FRCP(C)

Jeanette Scott, MBChB, FANZCA Kitt Turney, MD

Jennifer W. Zhan, MD Jinbin Zhang, MBBS, MMED (Anaesthesiology)

Evaluation of the Airway

They sailed.(16) They sailed.(17) Then spake(18) the mate:

Then pale and worn,(24) he paced his deck

A Suggestive Outline for the Study of a Selection

I. Mastery of Main Theme

II. Progressive Analysis

III. Reference to Experience

1. If we are reading a description, we will see this scene in

Question: What experiences does this selection call upon from

1. What significant words are used?