**2. Airway management**

#### **2.1. Introduction**

Emergency airway management is considered one of the most difficult fields of the emergency care. In order for physicians to provide proficient and effective care, they must be trained to a competent and highly efficient level of proficiency in maintaining, assessing, and managing airways using both basic airway maneuvers and advanced skills such as rapid sequence intubation (RSI). The physician's decision-making process is the core principle of highly safe and effective airway management. The decision made by the physicians should ensure the accomplishment of airway security and improvement of ventilation and oxygenation while ensuring there are none or minimal iatrogenic errors or defaults [1].

#### **2.2. Basic airway management**

The most initial part of airway management in sick patient is to assess for airway adequacy and patency and risk for compromise and take a decision for further intervention. Delivering oxygen to the lungs and ensuring a clear airway are the key principles of airway management. For this to be done, physicians must ensure the airway is guarded from foreign objects such as blood and fluids. Once breathing discontinues the body's oxygen supplies dramatically and rapidly decrease; time is the most critical part of this process of airway management which takes us back to the extreme importance of accurate decision-making when assessing adequacy of airway alongside any risks of compromise. Blood, vomit, and other foreign bodies are the main cause of the blockade to the airways; however airway injury or swelling can also be a cause. These obstructions can be treated by many lifesaving interventions such as airway maneuvers, positioning, and correct ventilations [2–5].

#### **2.3. Airway anatomy**

physician (EP) to better understand and develop the required technical skills to achieve the

Emergency airway management is considered one of the most difficult fields of the emergency care. In order for physicians to provide proficient and effective care, they must be trained to a competent and highly efficient level of proficiency in maintaining, assessing, and managing airways using both basic airway maneuvers and advanced skills such as rapid sequence intubation (RSI). The physician's decision-making process is the core principle of highly safe and effective airway management. The decision made by the physicians should ensure the accomplishment of airway security and improvement of ventilation and oxygenation while

The most initial part of airway management in sick patient is to assess for airway adequacy and patency and risk for compromise and take a decision for further intervention. Delivering oxygen to the lungs and ensuring a clear airway are the key principles of airway management. For this to be done, physicians must ensure the airway is guarded from foreign objects such as blood and fluids. Once breathing discontinues the body's oxygen supplies dramatically and rapidly decrease; time is the most critical part of this process of airway management which takes us back to the extreme importance of accurate decision-making when assessing adequacy of airway alongside any risks of compromise. Blood, vomit, and other foreign

ensuring there are none or minimal iatrogenic errors or defaults [1].

highest level of care that will have direct impact on patients' outcome.

• Airway management

• Needle decompression

• Tube thoracostomy

• Pericardiocentesis • ED thoracotomy

• Transcutaneous pacing

**2. Airway management**

**2.2. Basic airway management**

• Defibrillator

**2.1. Introduction**

• Rapid sequence intubation

58 Essentials of Accident and Emergency Medicine

• Intraosseous line placement

• Central venous catheter placement

The chapter will cover the following resuscitative procedures of emergency:

A complete understanding and knowledge of anatomy is important for performing any procedure. Adverse events in any procedure usually happen either due to lack of understanding of the regional anatomy or as a result of inexperience. Performing an airway procedure with a thorough understanding of airway anatomy is not exceptional. Starting by assessing the airway looking for external anatomical landmarks till the completion of intubation, an understanding of the anatomy of the airway will lead to increased success rate and reduced attempts rate and iatrogenic errors. The upper airway includes the oral and nasal cavities, the pharynx, and the larynx. The lower airway comprises the subglottic larynx, the trachea, and the bronchi. It is a complicated system that transmits filtered warm air to the lungs through the trachea and at the same time permits passage of solids and liquids to the esophagus. However, if a food particle or liquid enters the airway, a complete system of reflexes will be activated to protect its integrity [3, 4]. **Figure1** shows the anatomy of the larynx, trachea, and pharynx (graphic jump location).

#### **2.4. Basic airway management techniques**

Basic airway management is the base for advanced airway skills. Although it is easy, it can be both tricky and lifesaving. In majority of patients, a combination of patient positioning, different airway maneuvers, use of airway adjuncts, and assisted ventilation will help maintain oxygenation and can be lifesaving [3].

#### **2.5. Positioning**

The sniffing position is the preferable way to open the upper airway and it is achieved by flexion of the lower cervical spine and atlanto-occipital extension. It can be accomplished by putting a pillow or folded towel under the patient's head, and the physician then extends the head on the neck to align the three airway axes oral, pharyngeal, and laryngeal axes[2, 3, 6].If cervical spine injury is suspected, maintain the neck in a neutral position. In obese patients the sniffing position can be achieved by putting a pillow under the shoulders and another pillow under the head to raise it further. Raising the head end of the trolley or bed also improves preoxygenation in obese patients by reducing the pressure of the abdominal contents on the diaphragm, thereby increasing the functional residual capacity [2].

#### **2.6. Head-tilt and chin-lift maneuver**

After patient positioning, there are other movements that improve the airway more. Head tilt and chin lift one of them, to perform it, place the tips of index and middle fingers under the patient's chin and pull the mandible forward to elevate the tongue and open the airway. The thumb then can be used to open patient's mouth by depressing the lower lip.

gently under direct vision. Using the sucker blindly might lead to airway injury, vagal stimulation, increased intracranial pressure, and vomiting. Intermediate negative pressure should be used to avoid blockage of the sucker. There are no contraindications to airway suctioning [3, 4, 6].

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 61

The oropharyngeal airways (OPA) are hard plastic devices with curved shape to lift the base

**Indications:** It is indicated for obstructed airway in an obtunded patient. Conscious patients

**Size**: The device is sized by measuring its length from the patient's incisors to the angle of

**Technique:** It is inserted inverted into the mouth after it passed the hard palate; the airway is rotated 180 degrees and advanced over the tongue. Another way is to use a tongue depressor

**Complications:** May induce vomiting in patients with intact gag reflex, laryngospasm, raised intracranial pressure, and risk of aspiration in patients who have some airway reflexes.

**Limitations:** As a rule, any patient who tolerates an OPA airway should have a definitive airway. OPA is not a definitive airway. It helps with oxygenation and keep the airway open,

**Indications:** NPA is indicated when OPA cannot be used. It can be used to open the airway of conscious or semiconscious patients with intact airway reflexes who cannot tolerate OPA.

to depress the tongue and advance the airway directly with no rotation needed.

Are soft rubber tubes with a bevel at one end and a flange on the other end.

**2.9. Airway adjuncts**

*2.9.1. Oropharyngeal airways*

**Figure 2.** Head-tilt and jaw-thrust maneuver.

will not tolerate an OPA.

but does not protect it.

*2.9.2. Nasopharyngeal airways (NPA)*

the jaw.

of the tongue forward and prevent obstruction.

#### **2.7. The jaw-thrust maneuver**

It is the favorite method for patients with possible cervical spine injury. To perform it, the tips of the middle or index fingers should be placed behind the angle of the mandible. Then lift the mandible upward to bring the lower incisors anterior to the upper incisors. Jaw thrust can be used together with the head tilt and chin lift and it is called the triple airway maneuver. The best description of this maneuver is head tilt, jaw thrust, and mouth opening [4] (**Figure 2**).

#### **2.8. Suction**

Patient positioning and airway opening maneuvers are usually insufficient to completely open the airway. Continuous vomits and bleeding usually need suctioning. The sucker should be used

**Figure 2.** Head-tilt and jaw-thrust maneuver.

gently under direct vision. Using the sucker blindly might lead to airway injury, vagal stimulation, increased intracranial pressure, and vomiting. Intermediate negative pressure should be used to avoid blockage of the sucker. There are no contraindications to airway suctioning [3, 4, 6].

#### **2.9. Airway adjuncts**

**2.7. The jaw-thrust maneuver**

60 Essentials of Accident and Emergency Medicine

**Figure 1.** Airway anatomy.

**2.8. Suction**

It is the favorite method for patients with possible cervical spine injury. To perform it, the tips of the middle or index fingers should be placed behind the angle of the mandible. Then lift the mandible upward to bring the lower incisors anterior to the upper incisors. Jaw thrust can be used together with the head tilt and chin lift and it is called the triple airway maneuver. The best description of this maneuver is head tilt, jaw thrust, and mouth opening [4] (**Figure 2**).

Patient positioning and airway opening maneuvers are usually insufficient to completely open the airway. Continuous vomits and bleeding usually need suctioning. The sucker should be used

#### *2.9.1. Oropharyngeal airways*

The oropharyngeal airways (OPA) are hard plastic devices with curved shape to lift the base of the tongue forward and prevent obstruction.

**Indications:** It is indicated for obstructed airway in an obtunded patient. Conscious patients will not tolerate an OPA.

**Size**: The device is sized by measuring its length from the patient's incisors to the angle of the jaw.

**Technique:** It is inserted inverted into the mouth after it passed the hard palate; the airway is rotated 180 degrees and advanced over the tongue. Another way is to use a tongue depressor to depress the tongue and advance the airway directly with no rotation needed.

**Complications:** May induce vomiting in patients with intact gag reflex, laryngospasm, raised intracranial pressure, and risk of aspiration in patients who have some airway reflexes.

**Limitations:** As a rule, any patient who tolerates an OPA airway should have a definitive airway. OPA is not a definitive airway. It helps with oxygenation and keep the airway open, but does not protect it.

#### *2.9.2. Nasopharyngeal airways (NPA)*

Are soft rubber tubes with a bevel at one end and a flange on the other end.

**Indications:** NPA is indicated when OPA cannot be used. It can be used to open the airway of conscious or semiconscious patients with intact airway reflexes who cannot tolerate OPA.

**Size:** The size can be estimated by measuring from the tip of the nose to the tip of the earlobe. An appropriate size of the NPA in adults is 6 mm internal diameter of an average female and 7 mm internal diameter for an average male [2, 3].

**3. Rapid sequence induction**

**3.1. Indication for intubation**

**1.** Apneic patient.

ineffective.

**3.2. Contraindications**

**3.3. Preparation for RSI**

**3.4. Assessment for difficult airway**

equipment.

this is done by:

Rapid sequence induction (RSI) is a guided protocol of steps to reduce complications and boost success. The protocol of RSI entails the administration of anesthetic induction drug, followed by muscle-relaxing drugs (neuromuscular blockade drug) to achieve complete paralysis.

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 63

RSI is the preferred method to secure an airway on an emergent basis and where there is a risk of aspiration of gastric contents. In experienced hands, it is a relatively safe procedure with few complications. The choice of pharmacologic agents used will vary by physician experience, physician preference, the clinical condition of the patient, and the pharmacology of the agents [4].

**2.** Patient with an obstructed/partially obstructed airway where basic airway care is

**3.** The patient requires invasive respiratory support for oxygenation or ventilatory failure.

a high probability of airway obstruction, aspiration, or ventilatory failure[2].

**4.** Patient in whom basic airway care is effective, but whose predicted clinical course includes

RSI has just few contraindications. Firstly, inexperienced intubator should not perform RSI. Secondly, when the physician is not sure of his capability to intubate a patient with difficult airway, then he has to perform awake intubation. There are also other contraindications to RSI such as the contraindications of the muscle relaxants and absence of required

Once the decision for intubation is taken, preparation for RSI should be started. The first attempt is always the best chance, so all efforts to make it successful should be done this by a systematic approach, maximizing the preintubation physiologic parameters of the patient

Before proceeding with preparations for RSI, assessment of patient for difficult airway should be done using the LEMON mnemonic which can be done easily on any critically ill patient;

and good teamwork which will all increase the success rate for intubation.

There are four clinical situations in which intubation may be indicated:

**Technique:** It is very simple. The airway should be lubricated first and then inserted gently into the nostril that looks wider and advanced it posteriorly with slight rotational movement. To improve the airflow, another airway can be inserted into the other side.

**Complications:** It may cause hemorrhage, nasal trauma, and laryngospasm and vomiting in a conscious patient with sensitive oropharynx [6].

**Limitations:** It is contraindicated to use NPA when there is a basal skull fracture or cribriform plate injury. These injuries might lead to intracranial placement of the airway. It is usually rare, and when there is life-threatening hypoxemia and where insertion of an OPA is not possible, careful insertion of NPA may be lifesaving [2].

The effectiveness of any airway maneuver or adjunct must always be assessed after it has been completed.

The oropharyngeal airway (OPA) and nasopharyngeal airway (NPA) are basic airway adjuncts. They are used to secure and open the airway, once it has been opened by either a head-tilt, chin-lift, or jaw-thrust maneuver and any objects or secretions have been removed by suctioning (**Figure 3**).

#### **2.10. Oxygenation**

The guidelines recommend that for most acutely ill patients, oxygen should be given to achieve a target saturation of 94–98% or 88–92% of those at risk of hypercapnic respiratory failure. Give all critically ill patients high flow oxygen 15 L/min until they are stable, and then reduce it to achieve the target saturation. These targets can be achieved by the use of nasal cannula, face mask with reservoir, or noninvasive ventilation (NIV) together with airway maneuver and adjuncts [2].

**Figure 3.** A-oropharyngeal airway, B- nasopharyngeal airway.
