Are You Prepared for the Difficult Airway?

Recognition and mitigation of deficits in the ABCs is a hallmark principle of resuscitation taught to every EMS provider and emergency physician during both initial and continuing education. While many consider management of the ABCs to be routine, lack of proper equipment and a plan for how to rescue the airway in those patients in whom orotracheal intubation cannot be successfully performed can be disastrous and commonly leads to high anxiety levels on the scene. This scenario is commonly referred to as “the difficult-airway patient” (see Table I).

Difficult-airway patients have been extensively studied in academic emergency departments across the country, because failed out-of-hospital airways, by definition, represent difficult airways to emergency physicians. There are several important concepts taught to emergency physicians about difficult-airway management that are also applicable to the EMS environment. First, training with alternative techniques and devices is essential to become comfortable with these procedures, since they are rarely performed. Second, redundancy helps to protect against systems failure. In other words, the more “tricks of the trade” the emergency physician and the paramedic have to choose from in a difficult situation, the more likely they will achieve success. Third, specialized equipment to manage these situations should be stored in a special cart or box and brought to the patient’s side whenever a difficult airway is predicted.

Table II lists six elements necessary to build an out-of-hospital difficult-airway capability. Recognizing that a rescue airway plan for failed intubation is mandatory is the first step in designing a difficult-airway capability. The second step is to create standardoperating procedures or guidelines for management of these patients. Such SOPs should include an algorithm to direct EMS personnel in what order to choose certain airway devices and techniques. Table III lists a variety of advanced airway management procedures and devices from which to choose, not all of which may be available or permissible in any particular EMS system. Next, specialized equipment must be purchased and housed in either the “first-in” bag or in its own box or bag (Table IV). The type and amount of equipment to be carried will dictate the choice of difficult-airway storage device and location. Finally, EMS personnel must be trained and in-serviced on this newly created system.

The Bryn Athyn Fire Company has had a difficult-airway SOP since the inception of ALS service (Table V); however, the equipment was squashed into the first-in bags (in which space is already at a premium) in a manner in which it was likely to be broken. This year, we consolidated the equipment into a stand-alone difficult-airway bag, which is stored under the squad bench. It is deployed for all known cardiac arrests and to scenes where a difficult intubation will be attempted. All police officers are familiar with its location.

Rapid sequence intubation is not permitted for ground EMS units in Pennsylvania. Facilitated intubation with Versed is available, but rarely used. Thus, we are most likely to run into a difficult-airway scenario in the setting of a cardiac arrest, and we have configured our bag with this in mind. Therefore, it also contains manual suction, a bag valve mask, an oxygen cylinder, three rounds of ACLS medications and various devices that are commonly used in airway management (CO2 detector, endotracheal tube-securing device, oral airways, etc.). The Hartwell-Grandview laryngoscope blade is housed in the intubation roll, which is kept in the first-in bag.