0071643192.pdf

AIRWAY MANAGEMENT

INDICATIONS FORDEFINITIVEAIRWAY

■ Failure to maintain a patent airway and protect against aspiration
■ Inadequate gag reflex and inability to handle secretions
■ Decreased mental status (GCS < 8) not due to a rapidly reversible
cause (eg, hypoglycemia, opioid overdose)
■ Severe maxillofacial trauma
■ Failure to adequately oxygenate or ventilate
■ Hypoxemia unresponsive to supplemental oxygen, as measured by pulse
oximetry with good waveform
■ Hypercapnea, as measured by ABG or end tidal CO 2 (ETCO 2 ) with
decreased mental status or other adverse effect
■ Anticipated clinical deterioration
■ Status epilepticus, multiple trauma +/−head injury, certain overdoses
(TCA), penetrating neck trauma, tiring asthmatic, etc.

EMS presents with an obese 34-year-old male with cerebral palsy who is

unconscious after a fall. On examination, he is unresponsive, GCS 6, with

shallow sonorous respirations. He has obvious facial trauma, a receding

mandible and a short neck, but his beard is well lubricated to facilitate bagging.

How do you prepare for his intubation?

This patient has several markers of a difficult airway, including obesity, facial

trauma, facial hair, receding mandible, and a short neck. This is a patient for

whom you want to have back-up plans in case endotracheal intubation attempts

fail. Preparation for advanced airway procedures is key.

RECOGNIZING THEDIFFICULTAIRWAY

Routinely evaluating patients for markers of difficult intubation, bag mask
ventilation, and cricothyrotomy allows the emergency physician to thought-
fully plan alternative approaches.

■ Difficult bag-valve mask (BVM)
■ Difficult mask placement
■ Edentulous, bearded, abnormal facies, facial trauma
■ Difficult mask ventilation
■ Obese, airway obstruction, stiff lungs, advanced pregnancy
■ Difficult laryngoscopy and intubation
■ Abnormal neck mobility
■ Immobilization, surgery, ankylosing spondylitis
■ Limited mouth opening
■ Less than three patient fingerbreadths between the upper and lower
teeth.
■ Poor oral access
■ Mallampati score (see Table 1.1 and Figure 1.1)
■ Prominent incisors
■ Receding mandible: Less than three patient fingerbreadths from the
mentum to the hyoid bone

RESUSCITATION

Be sure to correlate ABG

findings with the patient’s

clinical status.