Securing the airway and assuring adequate ventilation are the first priorities in the resuscitation of any acutely ill or injured patient. Without a patent airway and adequate gas exchange, other resuscitative measures will usually be futile. Thus, attention to the airway must precede or occur simultaneously with any other type of management. The exception is the initial defibrillation in cardiac arrest due to ventricular fibrillation, if it can be performed immediately. (See Figure 10–1.)
Management of the compromised airway. I-LMA, intubating laryngeal mask airway; LMA, laryngeal mask airway; PTTJV, percutaneous transtracheal jet ventilation; RSI, rapid sequence induction.
First, determine the patient's level of consciousness and note the presence of respirations and grade respiratory effort. In patients with known or suspected cervical spine (C-spine) injury, all assessments and maneuvers should be undertaken with the C-spine immobilized in a neutral position to prevent cord injury.
Apneic, Unconscious Patients
If the C-spine is not injured, place the head in the sniffing position with the chin lift maneuver to open the airway (Figure 10–2). For patients with potential C-spine injuries, a jaw-thrust maneuver should be used. Clear the airway of obstructions, using a rigid suction catheter to remove any blood, vomitus, or secretions from the oropharynx. Remove any large obstructing foreign bodies from the oropharynx manually or with Magill forceps (see Chapter 9).
In the sniffing position, the head is slightly extended and the neck is flexed on the shoulders. This aligns the axis of the airway with the mouth and pharynx, facilitating direct visualization of the cords during intubation. It is particularly important in young children and infants, in whom the larynx is considerably more anterior. A pad beneath the occiput improves flexion of the neck. This position cannot be used when there is cervical spine injury.
If the patient remains apneic, assist ventilation using a bag–valve–mask device (eg, Ambu bag) or mouth-to-mouth breathing (see Chapter 9). If adequate personnel and equipment are available, immediately perform endotracheal intubation.
Patients with Respiratory Effort
Administer high-flow oxygen. Clear and position the airway as described above. Identify evidence of upper airway obstruction. Prolapse of the tongue and accumulation of secretions, blood, or vomitus are common causes of obstruction. Signs may include wheezing, sonorous respirations, stridor, cough, and dysphonia. Upper airway obstruction should be removed if present. Back blows or the Heimlich maneuver may clear the obstruction. If not, use suction or direct visualization and a Magill forceps or finger. Blind finger sweep is contraindicated. Obstructions that recur or persist require endotracheal intubation, either orotracheally or via cricothyroidotomy, tracheostomy, or percutaneous transtracheal jet ventilation (PTTJV) (see also Chapters 7...