Airway management Study Guide

📖 Core Concepts Airway Management – maneuvers & procedures that keep the airway open for gas exchange. Basic vs. Advanced – basic: non‑invasive (head‑tilt‑chin‑lift, oral/nasal airways); advanced: specialized equipment (supraglottic & infraglottic devices, surgical airways). ABC Mnemonic – A = Airway; the first step in any emergency response. Patency Check – If a patient can speak, the airway is considered open. Cervical‑Spine Protection – Always assume C‑spine injury until cleared; choose jaw‑thrust over head‑tilt‑chin‑lift. --- 📌 Must Remember Obstruction hierarchy: Cough → Back slaps → Abdominal thrusts → Chest thrusts (if abdomen unavailable). Finger sweep – ONLY when the patient is unconscious and the object is visible. Nasopharyngeal airway – Contraindicated with suspected basal skull fracture. Oropharyngeal airway – Only in deeply sedated/unresponsive patients (avoid gag reflex). Laryngeal mask airway (LMA) – Easier than endotracheal tube (ETT) but offers less aspiration protection. Cricothyrotomy – Emergency, faster than tracheotomy, no neck extension needed. Tracheotomy – Preferred for long‑term ventilation; lower infection risk than emergent cricothyrotomy. Trauma airway tip: If mask seal impossible (facial hair, burns) → consider supraglottic or surgical airway. --- 🔄 Key Processes Treating an Obstructed Airway (adult) Encourage cough; allow forceful cough to expel object. If coughing fails → hard back slaps (patient leaning forward). If still blocked → abdominal thrusts (Heimlich): stand behind, grip abdomen, upward thrusts. If abdomen cannot be compressed (pregnancy, obesity) → chest thrusts on lower sternum. After successful clearance, re‑assess patency (ask “Can you speak?”). Pediatric (<1 yr) Obstruction Place infant head‑down (head‑tilt‑chin‑lift avoided). Apply back slaps followed by chest thrusts (instead of abdominal thrusts). Insertion of a Nasopharyngeal Airway (NPA) Measure from tip of nose to earlobe → appropriate length. Lubricate with viscous lidocaine gel. Gently insert along the nasal floor, aiming toward the earlobe, until resistance (pharynx). Insertion of an Oropharyngeal Airway (OPA) Choose size: flange = distance from incisors to angle of mandible. Insert upside‑down, then rotate 180° as it passes the palate. Ensure the tip sits in the vallecula, not the epiglottis. Emergency Cricothyrotomy (adult) Palpate cricothyroid membrane (between thyroid cartilage & cricoid). Make a vertical skin incision, then a horizontal incision through the membrane. Insert a cuffed or uncuffed tube, confirm ventilation (chest rise, CO₂ detector). --- 🔍 Key Comparisons Head‑tilt‑chin‑lift vs. Jaw‑thrust HT‑CL: Simple, but contraindicated with possible C‑spine injury. Jaw‑thrust: Preferred when C‑spine injury is suspected. Nasopharyngeal vs. Oropharyngeal Airway NPA: Works with clenched jaw or semi‑conscious patients; no if basal skull fracture. OPA: Rigid, must be used only in unresponsive patients; can trigger gag reflex. Supraglottic (LMA) vs. Infraglottic (ETT) LMA: Easier, less trauma, less protection from aspiration; limited in obese/long surgeries. ETT: Gold standard for aspiration protection, required for long‑term ventilation. Cricothyrotomy vs. Tracheotomy Cricothyrotomy: Rapid, bedside emergency, no neck extension. Tracheotomy: Surgical, for prolonged airway support, lower infection risk, performed in OR. Abdominal thrusts vs. Chest thrusts Abdominal: First line for adults; avoided in pregnancy/obesity. Chest: Alternative when abdomen cannot be compressed. --- ⚠️ Common Misunderstandings “Always do a finger sweep.” – Only when the object is visible and the patient is unconscious. “Head‑tilt‑chin‑lift is safe for every patient.” – It can worsen a cervical spine injury; use jaw‑thrust instead. “LMA protects as well as an ETT.” – LMA offers less protection against aspiration. “Cricothyrotomy can be used in children of any age.” – Avoid in children < 12 yr; tracheotomy is preferred if possible. “Advanced airway is always best in out‑of‑hospital cardiac arrest.” – Evidence shows basic airway (HT‑CL, BVM) may improve survival in many OHCA scenarios. --- 🧠 Mental Models / Intuition “Can they speak? → Airway open.” Simple bedside test. “Cough first, then strike, then thrust.” Think of a three‑step ladder of increasing force. “C‑spine = protect → jaw thrust.” Visualize the neck as a fragile column; only move the mandible. “Supraglottic = sits on top; infraglottic = goes through.” Picture a hat (LMA) vs. a pipe (ETT). --- 🚩 Exceptions & Edge Cases Pregnancy / severe obesity – Use chest thrusts instead of abdominal thrusts. Children < 1 yr – Head‑down positioning; chest thrusts, not abdominal. Basal skull fracture – Never insert a nasopharyngeal airway. Morbid obesity, lengthy surgeries, airway surgery – Prefer ETT over LMA. Cervical‑spine immobilization – Cricothyrotomy is favored over tracheotomy in emergencies (except young children). --- 📍 When to Use Which | Situation | Preferred Maneuver / Device | Rationale | |-----------|----------------------------|-----------| | Unconscious, no C‑spine concern | Head‑tilt‑chin‑lift + BVM | Fast, simple | | Suspected C‑spine injury | Jaw‑thrust + BVM | Protects spine | | Jaw clenched / semi‑conscious | Nasopharyngeal airway | Fits without opening mouth | | Deeply sedated, unresponsive | Oropharyngeal airway | Prevents tongue obstruction | | Need quick, non‑invasive airway in OR | LMA (extraglottic) | Easy insertion, less trauma | | High aspiration risk, long ventilation | Endotracheal tube (ETT) | Best seal & drug delivery | | Massive facial trauma, cannot mask ventilate | Cricothyrotomy (adult) | Fast, no neck extension | | Long‑term ventilation, stable patient | Tracheotomy | Lower infection, comfort | | Pregnancy, obesity, abdominal thrust contraindicated | Chest thrusts | Same force, avoids abdomen | --- 👀 Patterns to Recognize Unable to speak + noisy breathing → airway obstruction (needs immediate obstruction algorithm). Gurgling / wheezing after trauma + blood/vomitus → airway contamination → consider early surgical airway. Facial hair / burns → difficulty achieving mask seal → jump to supraglottic or surgical airway. Chest rise without breath sounds after intubation → possible esophageal intubation → reassess tube placement. --- 🗂️ Exam Traps Distractor: “Always perform a finger sweep in choking.” – Wrong; only when object visible & patient unconscious. Distractor: “Head‑tilt‑chin‑lift is the best first step in trauma with suspected C‑spine injury.” – Wrong; jaw‑thrust is safer. Distractor: “LMA provides equal aspiration protection to an ETT.” – Incorrect; LMA offers less protection. Distractor: “Cricothyrotomy is the airway of choice in children under 12.” – Incorrect; tracheotomy is preferred for kids. Distractor: “Advanced airway should be placed first in out‑of‑hospital cardiac arrest.” – Evidence favors basic airway (HT‑CL, BVM) in many OHCA cases. ---