Chapter 1: Resuscitation

AIRWAY MANAGEMENT

Decision to Intubate

• Failure to maintain a patent airway

  • Impending upper airway obstruction (eg, facial burns, severe angioedema, penetrating neck trauma, expanding hematoma, foreign body, epiglottitis)

  • Severe maxillofacial trauma

• Loss of protective reflexes

  • Lack of spontaneous swallowing, inability to handle secretions, or loss of gag reflex.

  • Approximately 12%-25% of adults do not have a gag reflex; therefore, inability to swallow is a more sensitive indicator for intubation than lack of gag reflex.

  • Decreased level of consciousness (Glasgow Coma Scale [GCS] < 8) not due to a rapidly reversible cause (eg, hypoglycemia, opioid overdose).

• Failure to adequately oxygenate or ventilate

  • Hypoxemia, unresponsive to supplemental oxygen, as measured by pulse oximetry with good waveform

  • Hypercapnia, as measured by arterial blood gas (ABG) or end-tidal CO₂ (ETCO₂). May be due to diminished central respiratory drive (eg, central nervous system [CNS] injury, sedatives, alcohol) or a peripheral process (eg, Guillain Barré, myasthenia gravis, muscular dystrophy)

• Anticipated clinical deterioration

  • Status epilepticus, poly-trauma (± head injury), certain overdoses (tricyclic antidepressants [TCAs], tiring asthmatic, etc)

Basic Airway Maneuvers

Basic airway maneuvers may prevent further need for intervention.

Airway Positioning

Head tilt with chin lift to extend head on neck, or jaw thrust to elevate mandible if possible C-spine injury.

PATHOPHYSIOLOGY

Posterior displacement of the tongue and intrinsic muscle relaxation, causing the epiglottis to obstruct the laryngeal inlet, are the most common causes of upper airway obstruction in the supine unconscious or semiconscious patient.

Airway Adjuncts

Oropharyngeal and Nasopharyngeal Airway Placement

INDICATIONS

• Relieve upper airway obstruction from the tongue in the unconscious or semiconscious patient

• Adjunct to bag-valve-mask (BVM) ventilation

PROCEDURE

• Oropharyngeal airway (OPA)

  • OPAs come in multiple sizes. To determine the appropriate size, the flange of the OPA should be placed at the mouth and the tip should reach the angle of the mandible.

  • Insert the device while inverted → rotate 180° once well into the mouth (in order to avoid pushing the tongue posteriorly) → advance distal end into the hypopharynx.

  • Alternatively, compress ...