This document discusses strategies for managing difficult airways in emergency situations. It begins by outlining goals of predicting difficult airways, having appropriate plans, and confidence in "can't intubate, can't ventilate" situations. It then discusses factors that can help identify difficult airways through past medical history, physical exam findings like thyromental distance, and classifications like Mallampati. The document emphasizes having alternative plans for airway management if intubation fails, such as BVM ventilation, supraglottic airways, or surgical techniques. It stresses the importance of paramedics feeling prepared with multiple airway options when facing emergent difficult airway scenarios.

1. Emergency Airway and
Ventilation—The Difficult
Airway
By: Darryl Jamison
NREMT-P

2. Hey ya’ll watch this….

3. Goals
Predict a difficult airway based on clinical criteria
Plan for appropriate action in the difficult airway
Initiate appropriate plans of attack with confidence
in the “Can’t Ventilate/Can't Intubate” (CVCI)
situation
Become informed about some new (and not so
new) airway options out there.

4. What this class assumes
You already understand the basic anatomy of the
Airway
You already have a basic understanding of both
BLS airway maneuvers and Endotracheal
Intubation by Oral and Nasal means
You are familiar with needle and traditional
surgical airway procedures.
You are an experienced operator in the field of
EMS.

5. Function of the Respiratory
System
Pulmonary ventilation—
movement of air into and
out of lungs so that gases
in the alveoli are
continuously exchanged.
External respiration—gas
exchange between blood
and alveoli
Transport of respiratory
gases—02 and CO2
between lungs and tissue
Internal respiration—
gas exchange between
systemic blood and
tissue cells

6. Why do we Intubate?
Inability to protect and maintain patent
airway.
Failure of oxygenation or ventilation.
Anticipated need based on clinical course

7. Ideal conditions for intubation
Ideal Lighting, positioning, etc.
Plenty of assistance
Time to prepare, plan, discuss
Option to Abort
Empty Stomach
Back up available.

8. Ideal Pt. for intubation
Intact, clear airway
Wide open mouth
Pre-Oxygenated
Intact respiratory drive
Normal dentition/good oral hygiene
Clearly identifiable and intact Neck and Face
Big open Nostrils
Good Neck Mobility
Greater than 90 KG, Less than 110 kg.

10. Ped and Adult Normal Trachea
0

11. In Reality Our patients are:
Immobilized
Traumatized
Compromised
Prioritized
Beer-n-Pizza-ized

12. They Tend to look like This:

13. Or this…

14. Or this (after failed ETT)

15. Most of our Patients are already “difficult
airways” by “OR” Standards. Why should
EMS personnel try to further identify a
difficult airway?

16. The American Society of
Anesthesiology (AMA)has noted:
“… there is strong agreement among consultants
that preparatory efforts enhance success and
minimize risk.”
And “…The literature provides strong evidence
that specific strategies facilitate the management
of the difficult airway “
Thus Identifying a potentially difficult airway is
essential to preparation and developing a strategy.

17. What does this mean to us?
Well, many Anesthesiologist have the option to
“Abort” induction, or to work through a problem
with as much assistance as needed.
In the REAL WORLD of EMS that is seldom the
case for Paramedics.
However many of the BASIC principles are valid
in the clinical evaluation of Patients, and thus
valuable in our education as medics.
Knowing these principles will improve our
decision making process and Patient Care;.

18. How can we further identify a difficult
airway?
PMHx
Basic Physical Exam
Thyromental Distance
Dr. Binnions “Lemon” Law
Mallampati Classification

19. Past Medical History
Rheumatoid Arthritis
Ankylosing Spondylitis: Painful Stiffening of the
Joint
Cervical Fixation Devices
Klippel-Fiel Syndrome: Short wide neck, reduction in
number of cervical vertebrae, and possible fusion of
vertebrae.
Thyroid or major neck surgeries
Pierre Robin Syndrome: Small Jaw, cleft Pallet, No
Gag reflex, downward displacement of tongue
Acromegaly: Thickening of Jaw, Soft tissue
structures of the face, associated with middle age

20. Past Medical History (Continued)
Reduced Jaw Mobility
Epiglottitis
Tumors, Known Abnormal Structures
Previous Problems in surgery

21. Basic Physical Exam
Anything that would limit movement of the
neck
Scars that indicate neck surgeries
Kyphosis
Burns
Trauma, especialy instability of the facial
and neck structures.

22. ThyroMental Distance
Measure from upper edge of thyroid cartilage to
chin with the head fully extended.
A short thyromental distance equates with an
anterior larynx that is at a more acute angle and
also results in less space for the tongue to be
compressed into by the laryngoscope blade.
Greater than 7 cm is usually a sign of an easy
intubation
Less than 6 cm is an indicator of a difficult airway
Relatively unreliable test unless combined with
other tests.

23. Dr. Binnions Lemon Law: An easy way to
remember multiple tests…
Look externally.
Evaluate the 3-3-2 rule.
Mallampati.
Obstruction?
Neck mobility.

24. L: Look Externally
Obesity or very small.
Short Muscular neck
Large breasts
Prominent Upper Incisors (Buck Teeth)
Receding Jaw (Dentures)
Burns
Facial Trauma
S/S of Anaphylaxis
Stridor
FBAO

25. E: Evaluate the 3-3-2 rule
Greater than three fingers from Jaw to Neck
Jaw is Greater than 3 fingers wide
You can open the mouth greater than two
fingers

26. M: Mellampati classification
A Method used by Anesthesiologist, reliable
to predict difficult direct Laryngoscopy
(Cormack & Lehane grading)
A Class I view is a Grade I Intubation 99%
of the time
A Class IV view is a Grade III or IV
intubation 99% of the time

27. Mellampati Classification

28. Cormack & Lehane Grading

29. O: Obstruction?
Blood
Vomitus
Teeth (“chicklets”)
Epiglotis
Dentures
Tumors
Impaled Objects

30. N: Neck Mobility
Spinal Precautions
Impaled Objects
Lack of access
See PMHx for others.

31. What do we do when we have a
difficult airway?

32. So what do we do?

33. Before intubation
Is there another means of getting our
desired results BEFORE we attempt Direct
Oral ETT? (Especially if we RSI)
CPAP ?
PPV with BVM or Demand Valve?
Nasal ETT?
Do we have all the help we need, all Airway
equipment with us? (Suction?)

35. In Pediatric Advanced Life Support (PALS), the LMA™ airway is
classified as a Class Indeterminate device, defined as "Interventions
can still be recommended for use, but reviewers must acknowledge that
research quantity/quality fall short of supporting a final class decision.
Indeterminate is limited to promising interventions." Therefore, the
LMA™ airway may be utilized depending on the situation at the time
of the arrest.

37. What are we going to do if we don’t get the
Tube?
Plans “A”, “B” and “C”
Know this answer before you tube.

38. Plan “A”: (ALTERNATE)
Different Length of blade
Different Type of Blade
Different Position

39. Plan “B”: (BVM and BLIND INTUBATION
Techniques )
Cam you Ventilate with a BVM? (Consider
two NPA’s and a OPA, gentile Ventilation)
Combi-Tube? PTLA (No Longer produced)
EOA, EGTA?
LMA an Option?
Retrograde Intubation?

40. What do we do when faced with
a Can’t Intubate Can’t Ventilate
situation?
Plan “C”: (CRIC) Needle, Surgical,

41. Do YOU feel ready to enact
Plans A, B, C at a drop of a hat?
Feel familiar with all those tools and
techniques?
As Paramedics we should, After all we will
provide the only definitive care in these
patients.
ACEMS ED will be trying to increase
training in these areas.

42. Questions or Comments