The first step in every assessment is to evaluate for a secure airway. The following information is intended as a refresher, and does not substitute for hands-on training with an appropriate instructor. Always first open an airway by placing the head and neck in neutral position and then use a chin lift or jaw thrust. Any techniques that violate the skin should have sterile prep and drape performed. The cricothyroid membrane is bound by the inferior border of the thyroid cartilage above and the cricoid below. Use of topical anesthetics for some of these procedures may improve pt comfort and success, but benzocaine may cause methemoglobinemia (Arch IM 2004;164:1192).

N.B. Peds do well with bag-valve-mask (BVM) out of hospital compared with ET for medical or trauma in urban environment (Jama 2000;283:783).

Oral Pharyngeal Airway (OPA): This curved plastic airway may be the first step in oral airway adjunct. This is sized by having one end resting on the tip of the nose and the other end resting at the angle of the jaw. Insert with the concavity upwards, and then rotate 180° when it is halfway in. The final position is with the flange at the lips. This lifts the tongue from the back of the throat, and is not for use in a conscious person. Adult size is 5-6, with smaller numbers for smaller sizes.

Nasal Pharyngeal Airway/Nasal Trumpet (NPA): This is sized as with the OPA, and the lubricated tip goes through a nare, and the flange rests at the external nare when done. Many people have asymmetric nare passages—if it does not work on one side, try the other. Size 8-9 in adult (internal diameter in millimeters) may be used on the conscious pt, but should not be used in those with maxillofacial trauma.

Bipap/CPAP: May be useful for those in respiratory failure of medical cause (CHF, COPD, pneumonia) if pt can tolerate the device and intubation not clearly needed (Nejm 2001;344:481). Not for asthma.

Of note, non-invasive pos pressure ventilation for respiratory failure after extubation does not change the pt’s immediate future need for re-intubation or the incidence of short-term mortality (Nejm 2004;350:2452).

Combitube: A variant on the esophageal obturator airway (EOA), but with the ability to have both the side vent and distal end vent accessed for ventilatory support. In other words, the provider has the ability to be ventilate a pt independent of where the tip ends up (esophagus vs trachea). Is heat dependent, in that it becomes very stiff in a cold environment and may cause lacerations. Advance so that the teeth are between the two black lines on the tube, and then fill the blue balloon and then the white balloon. Vent attempting the blue port first—if not venting then try the white port. Two sizes, but even the small size necessitates the pt be > 5 ft in height. Currently is not available in a latex-free option.

Laryngeal Mask Airway (LMA): An anesthesia device that is a “save” device in emergency medicine, whose use would be considered for those in C-spine immobilization (Anaesthesia 1999;54:793) or when an endotracheal tube cannot be introduced successfully. The distal tip of this device sits in the posterior pharynx, is then
inflated to “occlude” the esophageal opening, and air vents just proximal to this area direct air toward the larynx. Not as secure as an endotracheal tube, and may intubate through this device with an endotracheal tube, sometimes using fiberoptic assistance (Ped Anaesth 2000;10:53)—the intubating laryngeal mask airway is of equivocal emergency usefulness (Anaesth Intensive Care 1998;26:387; Anaesthesia 1996;51:389).

Orotracheal Intubation: This tube is placed through the mouth and into the trachea. Peds tubes are uncuffed and can be sized using the pt’s little finger, or consulting a Broselow-Hinkle tape. Adult tubes are typically in the 7-8 range (internal diameter in millimeters), have an inflatable cuff. “Cricoid” pressure from an assistant helps (BURP—manipulate the thyroid cartilage in a Back or posterior, Up, and Rightward Pressure), and this is commonly known as the Sellick maneuver (Anaesthesist 1998;47:45). Confirmation of placement with checking for breath sounds over anterior lung fields and lack of sounds over stomach, CXR is confirmatory. Not uncommon to have right mainstem intubation, and simply withdraw the tube 2-4 cm. Caution in the prehospital realm with unrecognized misplacement [as high as 12% (Acad Emerg Med 2003;10:961), so perhaps two confirmatory maneuvers.

Nasotracheal Intubation: This can be done in a conscious adult pt, and the same caveats with NPA in re: facial trauma. The pt must have spontaneous respirations because listening and feeling for breath sounds at the end of the tube is the mechanism for guiding the tube into the trachea (J Emerg Med 1999;17:791). Lubricate the tip of the tube, insert through largest nare passage, and follow the breath sounds, with gentle back and forth rotation of the tube to facilitate placement. Application of oxymetazoline HCl 0.05% (Afrin) nasal spray and/or nebulzing 5 cc of 2% lidocaine with epinephrine prior to procedure may decrease nasal bleeding and pain. Advancing during early inspiration is the timing most
important to pass through the vocal cords. May be facilitated with digital intubation guidance (J Emerg Med 1989;7:275). Possibly the right procedure for angioedema not adequately managed with NPA.

Digital Intubation: A deeply comatose pt with obscure landmarks may be digitally intubated (J Emerg Med 1984;1:317). Place two fingers of non-dominant hand past the tongue and behind the epiglottis. Pass the tube down along the hand and use the two fingers at the epiglottis to guide the tube into the trachea. Not uncommon to have left mainstem intubation (Am J Emerg Med 1994;12:466). Beck airway air flow monitor (BAAM) may be helpful with these type of intubations, produces a whistle noise that intensifies with placement into trachea (Prehosp Disaster Med 1993;8:357).

Rapid Sequence Intubation (Ann EM 1993;22:1008): A protocol for allowing paralysis of a pt who is difficult to intubate, secondary to jaw clenching such as seen in those with head injury or seizures. Different protocols exist with all meds iv. Use of this sequence necessitates knowledge of these drugs, and learning about pre-anesthesia.

Pt assessment is key with a standardized approach for airway dynamics—eg, Mallapati or more complete LEMON approach (Look, Evaluate, Mallapati, Obstruction, Neck mobility).

Typically, pain and amnestic modulation can occur with a narcotic and a sedative (including barbiturates and benzodiazepines).

Premedicate: Use lidocaine in those with head injuries or eye injuries, atropine in children or in those with bradycardia, a narcotic for pain control and to block the sympathetic response, and a barbiturate, sedative, or benzodiazepine for amnesia. Special case for ketamine in those with status asthmaticus, but avoid in those with head injury (increases ICP).