1. Basic Emergency Airway Management Pat Melanson,MD
- the most essential skill in EM
- establishing or protecting on airway is frequently the essential maneuver for saving a person’s life
- conversely, failure to do so is the fastest way to assure a patient’s demise
- assessment and management of the airway have been appropriately assigned the A in the well known ABC’s of resuscitation for scientific reasons as well as alphabetic
Basic Emergency Airway Management Pat Melanson,MD

2. Objectives
Differentiate the Emergency Airway from elective intubation in the OR
Assessment of airway compromise
Indications for airway intervention
Recognition of the difficult airway
Bag-Mask Techniques
Laryngoscopy

3. Emergency Airway Management : Unique Considerations
Full stomach - high aspiration risk
Altered level of consciousness
Deteriorating cardiorespiratory physiology - (hypotension, hypoxia)
Abnormal or distorted upper airway anatomy
No time for “pre-op” assessment

4. Airway Assessment
Assessment for airway compromise or threats and need for interventions
Examination for the potentially difficult airway

5. Patency of Upper Airway Protection against aspiration
The Three Pillars of Airway Management: ( Assessment of Compromises or Threats )
Patency of Upper Airway
( airflow integrity )
Protection against aspiration
Assurance of oxygenation and ventilation

6. Indications for Active Airway Intervention: including intubation
Failure to maintain patency
Protection from aspiration
Hypoxic/ hypercapnic respiratory failure
Airway access for pulmonary toilet, drug delivery,therapeutic hyperventilation
Intractable Shock
Anticipated clinical deterioration

7. Indications for Intubation
Is there failure of airway maintenance ?
Is there failure of airway protection ?
Is there failure of oxygenation or ventilation?
What is the anticipated clinical course ? (i.e., expected deterioration, long transport, long time in radiology, etc.)

8. Clinical Signs of Airway Compromise : Threatened Patency
Inspiratory stridor
Snoring ( pharyngeal obstruction )
Gurgling ( blood/ secretions )
Drooling ( epiglottitis )
Hoarseness ( laryngeal edema/ vocal cord paralysis)
Paradoxical chest wall movement
Tracheal tug
Mass - abscess, hematoma, angioedema

9. Clinical Signs of Airway Compromise: Inadequate Protection
Blood in upper airway
Pus in upper airway
Persistent vomiting
Loss of protective airway reflexes
swallowing reflex is superior to gag reflex

10. Clinical Signs of Airway Compromise: Oxygenation and Ventilation
Central cyanosis
Obtundation and diaphoresis
Rapid shallow respirations
Accessory muscle use
Retractions
Abdominal paradox

11. Clinical Signs of Airway Compromise: Oxygenation and Ventilation
The assessment of oxygenation and ventilation is a clinical one.
Arterial blood gases should not be relied upon to assess whether intubation is necessary.

12. Techniques for the Compromised Airway
Head Positioning
Jaw Thrust, Chin lift
Orophryngeal/ Nasopharyngeal airways
Bag-Valve-Mask Ventilation
Endotracheal Intubation
Advanced techniques
Cric, LMA, Combitube, Retrograde, Fibreoptic, Light wand, Bouge

13. The Difficult Airway Difficult Laryngoscopy
poor visualization of cords
Difficult bag-mask ventilation
unable to oxygenate or ventilate
Lower airway difficulty
severe bronchospasm

14. Golden Rules of Bagging
“ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “
The art of bagging should be mastered before the art of intubation
Manual ventilation skill with proper equipment is a fundamental premise of advanced airway Rx

15. BVM Ventilation The most important airway skill
Always the first response to inadequate oxygenation and ventilation
The first “bail-out” maneuver to a failed intubation attempt
Attenuates the urgency to intubate
Do not abandon bagging unless it is impossible with two people and both an OP and NP airway

16. BVM Ventilation Requires practice to master One hand to
maintain face seal
position head
maintain patency
Other hand ventilates

17. BVM Ventilation: Technique
Insert oropharyngeal/nasopharyngeal
“Sniffing”position if C-spine OK
Thumb + index to maintain face seal
Middle finger under mandibular symphysis
Ring/little finger under angle of mandible
Maintain jaw thrust/mouth open

18. Predictors of a Difficult Airway : BVM
Upper airway obstruction
Lack of dentures
Beard
Midfacial smash
Facial burns, dressings, scarring
Poor lung mechanics
resistance or compliance

19. Difficult Airway : BVM degree of difficulty from zero to infinite
Zero = no external effort or internal device required
one person jaw thrust/ face seal
oropharyngeal or nasopharyngeal AW
two person jaw thrust / face seal
both internal airway devices
Infinite = no patency despite maximal external effort and full use of OP/NP

20. Algorithm for Difficulty “Bagging”
Remove Foreign Bodies - Magill forceps
Triple maneuver if c-spine clear
Head tilt, jaw lift, mouth opening
Nasal or oropharyngeal airways
Two-person, four-hand technique

21. BVM Ventilation: Mask Seal Tips and Pearls
Easier to get seals with masks too large than too small
Inflate mask collar correctly
Apply lubricant to beards to “mat down” hair
If edentulous insert gauze sponges into cheeks

22. Prediction of the Difficult Airway: Laryngoscopy
History of past airway problems
check previous OR anesthesia records if time permits
cricothyroidotomy scar
Careful physical assessment
mouth opening
tongue to pharyngeal size
hyo-mental distance
Neck flexion, Head extension

23. Technique of Laryngoscopy
“Sniffing” position to align oral-pharyngeal-laryngeal axis
Flex neck by placing pillow beneath occiput ( raise 10 cm )
Extend head maximally
With laryngoscope
open mouth fully
push tongue to left out of view
pull upward at 45 degrees

24. Adducted vocal cords

26. Predictors of Difficult Laryngoscopy
Short thick neck
Receding mandible
Buck teeth
Poor mandibular mobility/ limited jaw opening
Limited head and neck movement
( including trauma )

27. Difficult Airway : Laryngoscopy
Tumor, abscess or hematoma
Burns
Angioneurotic edema
Blunt or penetrating trauma
Rheumatoid arthritis, ankylosing spondylitis
Congenital syndromes
Neck surgery or radiation

28. Predictors of Difficult Laryngoscopy
3 fingerbreadths mentum to hyoid
3 fb chin to thyroid notch
3 fb upper to lower incisors
Head extension and neck flexion
Mallimpadi classification
Previous history of difficult intubation

29. Mallimpadi Classification (Tongue to Pharyngeal Size)
I - soft palate, uvula, tonsillar pillars visible
99 % have grade I laryngoscopic view
II - soft palate, uvula visible
III - soft palate, base of uvula
IV - soft palate not visible
100% grade III or grade IV views

30. The 4 D’s of Difficult Intubation
Distortion
( edema, blood, vomitus, tumor, infection)
Dysmobility of joints
( TMJ, alanto-occipital, C-spine)
Disproportion
thyomental, Mallimpadi, etc
Dentition
prominent upper teeth

31. Unsuccessful Intubation
Bag the patient
Maximize neck flex/ head ex
Move tongue out of line of site
Maximize mouth opening
ID landmarks and adjust blade
BURP maneuver (Backwards Upwards Rightwards Pressure on Thyroid Cart.)
Increasing lifting force
Consider Miller blade