Chapter 1. Advanced Airway Support

Control of the airway is the single most important task for emergency resuscitation.

The initial approach to airway management is simultaneous assessment and management of the adequacy of airway patency (the A of the ABCs) and oxygenation and ventilation (the B of the ABCs).

1. Assess patient's color and respiratory rate; respiratory or cardiac arrest may be an indication for immediate intubation.

2. Open the airway with head tilt–chin lift maneuver (use jaw thrust if C-spine injury is suspected). If needed, bag the patient with the bag-valve-mask device that includes an O2 reservoir. A good seal depends on proper mask size. This technique may require an oral or nasal airway or two rescuers (one to seal the mask with 2 hands and the other to bag the patient).

3. Provide continuous monitoring of vital signs, oxygen saturation, and end-tidal CO2 (if possible).

4. Determine the need for invasive airway management techniques. Do not wait for arterial blood gas analyses if the initial assessment indicates the need for invasive airway management. If the patient does not require immediate airway or ventilation control, administer oxygen by facemask to ensure an O2 saturation of 95%. Do not remove oxygen to draw an arterial blood gas analysis unless deemed safe from the initial assessment.

5. Preoxygenate all patients prior to intubation regardless of saturation. Assess airway difficulty before initiation of advanced airway techniques.

The most common means used to ensure a patent airway, prevent aspiration, and provide oxygenation and ventilation is orotracheal intubation. Rapid sequence intubation (RSI) should be used unless the patient's condition makes it unnecessary (ie, cardiac arrest) or it is contraindicated because of an anticipated difficult airway.

Emergency Department Care and Disposition

1. Prepare equipment, personnel, and drugs before attempting intubation. Assess airway difficulty and anticipate required airway rescue. Assemble and place suction, bag-valve-mask and rescue devices within easy reach. Personnel should be present at the bedside to pass equipment or bag the patient, if required.

2. Ensure adequate ventilation and oxygenation and monitoring while preparing equipment. Preoxygenate with a non–rebreather oxygen mask at maximal oxygen flow rates or with a bag-valve-mask if the patient is not ventilating adequately.

3. Select blade type and size (usually a No. 3 or 4 curved blade or a No. 2 or 3 straight blade); test the blade light. Select the tube size (usually 7.5 to 8.0 mm in women, 8.0 to 8.5 mm in men) and test the balloon cuff. The use of a flexible stylet is recommended.

4. Position the patient with the head extended and neck flexed, possibly with a rolled towel under the occiput. If C-spine injury is suspected, maintain the head and neck in a neutral position with an assistant performing inline stabilization.

5. With the handle in the operator's left hand, insert the blade to push the tongue to the patient's left and slowly advance to the epiglottis. Suctioning may be required. It is not uncommon ...