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Difficult Airway Management:

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Action-Plan for
Airway Problems From Hell!

by Tom Trimble, RN CEN

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What this article assumes: The reader is a healthcare professional with the responsibility of carrying out or assisting with airway management in emergency situations and has certification in ACLS/PALS, and experience with Rapid Sequence Drug-Assisted Intubation and of Sellick's Maneuver of Cricoid Pressure.

What this article will do: Help the emergency nurse to anticipate and be prepared for difficult and adverse events, to assess the possibilities, and to be more familiar with less commonly used techniques that may be appropriate for such events.

N.B.:This article is posted as a discussion of advanced practice airway management strategies for difficult and dangerously dynamic airway situations with high probability of adverse outcomes and in which experts may reasonably disagree or have preference for a different approach based on their experience, training, skill and confidence level. It does not comprehensively discuss all aspects of airway management or of care of the patient with an artificial airway. The purpose of the article is to promote thinking and planning for such situations before they occur. Our DISCLAIMER completely and specifically applies to all portions of this article.

Who?: "Who'ya gonna call?":

Who manages the airway and hand ventilates until the "airway manager" arrives?
Who manages airway/intubates?  Is that person physically present in the ED at all times?  Is it anesthesia on call?  Other person?
Is most intubation done by the ED doc, or medics in the field, and anesthesia for difficult cases?
Are you an academic facility where house officers in training intubate under supervision?
How many difficult intubations has your primary intubator done; how skilled are they at alternative techniques?
Who does the "surgical airway?" (How many have they done? Is what you have in stock the set of instruments they are used to using?)
Are the beeper or call numbers posted as well as memorized?


Backup Equipment:  What equipment is actually present and ready to hand for the difficult intubation? When were they last tested and checked? Are there spares? Who is responsible for them?
Needed for all airway control procedures:
Rapid-Sequence Drug-Assisted Intubation drugs?
( ---Are they in the room? . . . ---or in the "narcs" or refrigerator?)
Endotrol® Tracheal Tube with Controllable Tip? SIGN_update-yellowoval.gif (195 bytes)
Pulse Oximetry
Esophageal Intubation Detector Device?
Capnograph? and/or Capnometry
BAAM® "Beck Airway Airflow Monitor" or Ballistic Airway Monitor Whistles?
Anesthesia bags?
Is a ventilator ready in the dept.?
Indirect Methods of Endotracheal Intubation:
Light-Wand? Updated URL Recovered from Archived Source
                             c.f. Univ. of Florida's Lighted Stylet tutorial
Gum-Elastic Bougie?
Retrograde wire/catheter Guided Intubation? Updated URL Recovered from Archived Source
Alternate Airways:
Laryngeal Mask Airways? Updated URL Recovered from Archived Source
Combi-tube c.f. Univ. of Florida's Combitube tutorial
PharyngoTracheoLaryngeal Tube?
Esophageal Obturator Airway/Esophageal Gastric Tube Airway
Specialized Visualization:
Bullard Laryngoscopes? c.f. Univ. of Florida's Bullard Laryngoscope tutorial and
                                                                         Univ. of Florida's Upsher Laryngoscope tutorial
Fiber-optic Laryngoscope/Bronchoscope?
Surgical Airway Access:
Percutaneous Trans-tracheal Catheter Ventilation kit?
Cricothyrotomy set?
Tracheostomy set and tubes?
Other Questions:
How long does it take to get hold of Heli-Ox and who goes to get it?
How long does it take to get a high-frequency jet ventilator and who goes to get it?
Does any of this change at night or during "non-business hours?"

Fear and Fumbling {Valuable Maxims}:

"There is nothing to fear but fear itself."
Most airway problems, even extreme, can be worked as an algorithmic sequence of steps.
The best that can be done, under the circumstances, is the best that can be done.
If help can be called, do so early before the situation has utterly deteriorated.
Even a small partial airway may be sufficient to stave off cerebral death until help arrives.
Fall back to a simple method if it will at least temporize.
Even a modest plan may be successful if continued firmly.
Use any method in which one has confidence and experience, yet, if need be, pursue a method that seems applicable despite only textbook knowledge without experience.

Airway Clinical Crises:

Hypoxic trismus to be forcefully hand ventilated by mask.
Prepare NeuroMuscularBlockade or Nasal Intubation.
Limited mouth opening may require a low profile straight blade, light wand, or nasal intubation.

Updated URL Recovered from Archived Source

        May be due to inadequate sedation/local anesthesia/rapid sequence drug-assisted intubation, foreign matter on the vocal cords, drug effect, or idiosyncratic/anaphylactoid reaction. Move rapidly through attempted high-pressure manual ventilation, paralysis with a neuromuscular blocker, or cricothyrotomy.

Massive Emesis/Hemorrhage:

        PREVENT by assuming "full-stomach", Sellick's Maneuver of Cricoid Pressure, if spontaneously breathing ALLOW TO VENTILATE SELF if respiration adequate (or gentlest hand ventilation with Sellick's if not) to pre-oxygenate while preparing for Rapid Sequence Drug-Assisted Intubation. Maintain GOOD airway support through exhalation as well as inhalation phases and avoid excessively "quick" or "high" peak airway pressures: ALL to lessen likelihood of gastric insufflation and increased risk of regurgitation/aspiration!
Trendelenburg's Position.
Wide-bore suction.
NGT Gastric Decompression.
Blow-By O2 for the breathing patient while suctioning to minimize desaturation.
Gauze Roll oral packs for cheek and facial injuries.
Gauze swabs on a "Sponge-Stick" clamp or use the long vaginal swabs.

        If emesis, consider an EGTA or other barricade to further contamination, swab and suction, intubate the trachea "around " the esophageal tube, then follow with gastric decompression and suction.

        If hemorrhage into the airway, support blood pressure with fluids only to minimal acceptable levels until hemostasis is achieved in the operating room or bronchoscopy suite lest re-hemorrhage occurs.
        It may be necessary for an assistant to compress the chest firmly so as to produce a passive exhalation that might show bubbles in the supra-glottic fluid accumulation indicating the location of the trachea.
Facial Mash/Trauma { fracas du visage}:
        Towel clip, suture, or safety-pin for pulling tongue forward may be necessary if stability of mandible is lost.
        Assistants to support the jaw and face, and manually stabilize the neck in neutral position.
        Updated URL Recovered from Archived Source Sellick's Maneuver of Cricoid Pressure to prevent passive aspiration.
        Suction. Large-bore suction with dental tip to be preferred to Yankauer Tonsil Tip which is preferred to suction catheters until a definitive airway is achieved. Use the open suction tubing if need be.
        Cricothyrotomy should be simultaneously made ready if orotracheal intubation cannot be accomplished.

Short Jaw:

        Mask ventilation may require jaw lift (triple airway maneuver), use of both hands to hold the mask, or insuring good cuff seal of the mask against the face. Cricoid pressure may help visualize the cords. May need a straight blade or a short blade to lift only the jaw. A "hockey-stick" angulation of the tube on the stylet may be necessary to help enter the larynx. Transilluminated intubation may work well. Laryngeal Mask Airway.
Wired Jaw (or limited jaw-opening):
        While maintaining the jaws wired shut maintains the anatomic architecture in structural relationship (which is good), if nasal intubation cannot rapidly be achieved ---then the cricothyrotomy, for which one should simultaneously prepare, should proceed.
        Good mask ventilation may be sufficient for a brief procedure but is no substitute for a definitive airway.
        Copious vomiting in the presence of a wired jaw (or trismus) is a disaster: dependent positioning, a tonsil-tip or suction hose passed para-buccally and posterior to the hindmost molar may help. Wire-cutters or Diagonal Cutting Pliers must be kept at the bedside or on the patient's bed/body.
Total Orthopnea & Awake: (patient will not tolerate supine position)
Pre-oxygenate to 100% oxygen saturation X 3-5 minutes for nitrogen wash-out.
        Rapid-Sequence Drug Assisted Intubation and orotracheal intubation, if strong probability of successful intubation and patient can be ventilated manually if put down for supine intubation.
        Awake-Nasal Intubation (after adequate topical anesthesia and preparation) which preserves the patient's spontaneous ability to breathe should be planned if doubtful ability to intubate, or if the patient would be at greater risk if supine due to obesity or secretions.
        If it is necessary to intubate the patient in the upright position, e.g. due to pulmonary edema or obesity, it may be necessary to stand above the gurney to achieve Direct Laryngoscopy and pass the tube orotracheally, or nasotracheally with Magill's Forceps.
        Nebulized 4% Topical Lidocaine Solution (4ml=160mg) via aerosol mask can provide topical anesthesia of the airway, cough suppression, and blunt increases in intracranial pressure from noxious stimuli. A physician skilled in nerve blocks could do a regional block of the airway.
        Consider Ketamine. It is a dissociative sedative, analgesic, and amnestic, which acts also as a bronchodilator, preserves airway reflexes and respiratory effort.
        Digital or Transilluminated Intubation: If patient is upright or entrapped in such position within a vehicle or cave-in or burial within bulk materials such as grain, snow, sand, these methods can be used in the obtunded patient to whom access is limited to intubate the trachea. If the patient is awake but can have local anesthesia of the airway or block, perhaps with some sedation, the tube may be guided by tactile guidance, transillumination with a Light Wand, or Gum Elastic Bougie, or through a Laryngeal Mask Airway. Combitube may be useful to stabilize the patient until the airway can be optimized under better conditions.
        Fiber-Optic Laryngoscope (but may mandate a smaller tube which increases airway resistance).

Unconscious Patients Trapped Sitting Up In Car:

        Laryngoscopic Intubation From The Front:  "The technique is very simple. Have someone maintain C-spine immobilization (collar can be in place or not), have plenty of O2 on board, make sure sat is 100%, then using the Mac just hook it into the mouth and pull straight forward. Look in and Voila!
        The person controlling C-spine should be experienced and know what s/he is doing.  Must be very careful not to let it move. If done right, the only movement will be the mandible, which will simply be jutted as in the jaw thrust."  (William E. Gandy, JD, EMT-P , EMS Professions Program Director, Tyler Junior College, Tyler, TX, personal communication)

Status Asthmaticus:

See "Total Orthopnea & Awake" above.
        If anatomically difficult intubation foreseen, prepare for oral or nasal intubation and consider intravenous Ketamine for dissociation, analgesia, amnesia, with direct bronchodilatory response to Ketamine, and nebulized 4% Topical Lidocaine, 4 ml for topical anesthesia of the airway and blunting of cough. If nasal intubation is planned, pre-connect the soft anesthesia bag to the Endotrol® ETT to allow continuous oxygenation during intubation and immediate visible confirmation of tidal airflow when the cords are passed.
Ventilation: (Hand or Automatic Ventilator) Slow inspiratory time avoiding excessive peak airway pressures, allow adequately long expiratory time. Continue bronchodilation measures. Paralyze.

Massive or Morbid Obesity (obesity 100%>"ideal" body weight):

        Whenever possible, the patient should be nursed in an upright position so that the weight of the abdominal viscera and pannus will not interfere with diaphragmatic motion. As the lungs do not increase in size with obesity, the efficiency of respiratory mechanics must be maximized.
        If the patient must be "flat" then, if possible, place the patient in Left Lateral Recumbent or Recovery Position, so as to minimize pressure on the diaphragm or inferior vena cava, minimize esophageal reflux from the stomach through the gastroesophageal junction, and to put the Right Mainstem Bronchus and the three lobes of the right lung uppermost.
        Give supplemental oxygen regardless of present saturation. Prop and support the head and neck for best "sniffing position". Consider a nasopharyngeal airway or endotracheal intubation.
        Mask ventilation may require one person to manipulate the mask, jaw, head, and neck using both hands, and another person to squeeze the bag. This favors the use of an anesthetic bag with its long flexible neck or the interposition of corrugated mist tubing between the Laerdal's non-return valve and the bag itself. The "Seal-Easy" mask from Respironics is especially useful as it conforms with great ease to any difficult facial anatomy and its softness allows full use of both hands to perform the triple-airway maneuver and prevent leakage.
        Consider the use of PEEP or CPAP/Bi-PAP™, especially with somnolent patients, to help keep the alveoli and airway soft-tissues open. The weight, mass, and redundancy of airway soft-tissues in such a body habitus predisposes to Obstructive Sleep Apnea for which CPAP or Bi-PAP™ are principal treatment.
        Intubators who are small of stature may need physical assistance in laryngoscopy to support the weight of the jaw, head, and neck. Careful positioning in sniffing position with towels and props may be necessary to line up the axes of the trachea, pharynx, and mouth.
        Consider standing upon the bed or step-stool with patient in sitting (High Fowler's Position) position and perform Laryngoscopic Intubation From The Front, awake, after nebulized Lidocaine or thorough Viscous Lidocaine Swish, Gargle, & Swallow.
        While a large curved Mackintosh blade may help shove the tongue to one side and keep it there, a large #4 straight blade such as a Miller or Wis-Hipple may have the longer reach, better compression of the tongue and soft tissues above it, and be able to hold a floppy epiglottis up out of the way.
        Avoid neuromuscular blockade and rapid sequence drug-assisted intubation if there is doubt as to ability to ventilate the patient if apneic. Loss of effort, and of muscle tone and support may fatally convert a marginal airway into an unretrievable one.
        When unable to find a suitable vessel for arterial blood gas determination in a 700 lb. patient, an approximation of respiratory sufficiency was made with pulse oximetry and expired air CO2 concentration with a close-fitting anesthesia mask.

Airway Management of the Obese
from the ENW! article
Outsize Patients
--a big nursing challenge!

   Airway management problems in obese patients are rightfully dreaded. Difficult intubation is common, but prediction rules may over-predict and intubation may be, but not invariably, easier than anticipated. Several factors increasing risk and difficulty of intubation may be present:

  • Formulate an airway management plan when first encountering the obese patient. If difficult intubation is anticipated, or intubation becomes necessary, have back-up help present.
  • Facial anatomy needs appropriate mask selection for close fit and ease of holding by the "airway manager.".
  • Increased mass of soft tissues needs special techniques.
  • Macroglossia – large tongue may need oral airway for mask ventilation, and obscures laryngoscopy.
  • Weight of head increases exertion during laryngoscopy.
  • Head Tilt & "Sniffing Position" may require building up towels or blankets under the back, scapulae, and shoulders, as well as the head and neck, in order to provide sufficient "lift" and visual alignment of the axes of mouth, pharynx, and trachea for intubation. This also may be necessary to augment the nasopharyngeal airway or oropharyngeal airway used in spontaneously breathing patients
  • CPAP [constant positive airway pressure] may be needed to distend airway walls and prevent collapse during negative pressure phases of respiration.
  • Bi-level Non-Invasive Ventilation may be needed to support breathing and airway issues.
  • Mask ventilation may require two persons: one to use two-handed mask technique with triple airway maneuver, airway device, and CPAP; with another to bag the patient and monitor effectiveness. The preferred ventilating bag would be a "Jackson-Rees Circuit" anesthesia bag, if a skilled user is available. However, as the anesthesia bag is dependent on a constant supply of compressed gas, a self-refilling Bag-Valve-Mask should always be at hand in case the tank becomes empty or other failure of compressed gas supply occurs.
  • Use an appropriately sized oropharyngeal or nasopharyngeal airway whenever possible, and especially use an OPA if the patient is edentulous.
  • The Intubator may be more comfortable and prudent if another skilled Intubator or Anesthesiologist is present to assist or to initiate Difficult Airway intubation.
  • Must be certain of ability to mask ventilate, if intubation should be difficult or impossible, before sedation or paralysis deprives the patient of ability to breathe spontaneously:
                    -beware of "can’t ventilate, can’t intubate" situations!
  • "Bull Neck" – short, thick neck inhibits mobility and makes visualization of the larynx difficult during laryngoscopy.
  • Have "rescue" alternative airway devices ready to hand: e.g., Laryngeal Mask Airway (LMA) or Intubating LMA (Fastrach™); Elastic Gum Bougie; Lighted Stylet; Esophageal Combi-Tube™; Fiber-optic Laryngoscope or Bronchoscope.
  • The first intubation attempt should be by the most experienced intubator available working under optimized conditions. Each additional "attempt" worsens subsequent laryngoscopy conditions with swelling and airway trauma from repeated instrumentation.
  • If the first best attempt determines difficult or impossible laryngoscopy or intubation, change to either Rescue Airway plan (if patient condition is critical), or early Fiberoptic Intubation before airway trauma worsens the situation.
  • Fiberoptic laryngoscopy/bronchoscopy may be facilitated by using CPAP with an endoscopy mask, such as the Patil-Syracuse, which permits ventilation and simultaneous passage of the endoscope through an elastic port. Oxygenation and CPAP might also be delivered via a nasopharyngeal airway to which an endotracheal tube connector of the same size is fitted.
  • "Bull Neck", neck edema, or subcutaneous emphysema, may make landmarks for cricothyrotomy or tracheotomy difficult to discern or impossible to use.
  • Large breasts may get in the way of the laryngoscope handle (half-size handles are available).
  • Response to induction agents is less predictable.
  • Auscultation of breath sounds is distant.
  • Confirmation of endotracheal intubation should be by three or more methods including either capnometry or capnography.
  • Respiratory distress may necessitate "awake" intubation in sitting position.
  • Obese patients will desaturate oxygen rapidly due to decreased functional reserve capacity, weight of viscera upon diaphragm, compliance changes and weight of chest wall to elevate with accessory muscles of respiration. All seriously ill obese patients (in the emergency setting) should have supplemental oxygen regardless of room air SpO2. All obese patients with airway problems or impending intubation should have 100% oxygen to de-nitrogenate their tissues. Monitor patient for fatigue of respiratory muscles; as the patient becomes "quieter" and sleepy---hypercapnia may be increasing!
  • Percutaneous cricothyrotomy or surgical tracheostomy may be difficult due to additional distance from skin to tracheal wall and less-easily identifiable landmarks.
    --If feasible, such procedures should be deferred to the Operating Room and Team, or be done with a flexible fiberoptic bronchoscope that can ventilate the patient and confirm the intratracheal placement of the tracheostomy cannula without false passage into other planes of tissue.
    --For surgical tracheostomy, use of a skin hook to "maintain the hole" by holding onto cartilage during the procedure and placement of "stay sutures" to retract the wound in the event of accidental decanulation would be highly prudent precautions.
  • Provide extension tubing between the resuscitation bag and the non-rebreathing valve for intubated patients being transported so as to lessen risk of extubation. Such transports are necessarily cumbersome, require long "reaches", and have extra people in the way.

Aspirated Masticated Mess:

        The most difficult "choking" obstruction may not be the classic "cafe coronary" by a piece of steak, the size of a package of cigarettes, which may respond to a Heimlich Maneuver. A bolus of chewed peanuts or similar sticky matter can be extremely difficult to remove or breakup.
        If no response to Heimlich Maneuver and unable to intubate, go immediately to cricothyrotomy to bypass the obstruction. If the mass is intratracheal or endobronchial and unable to ventilate the situation is grave.
        If any partial airway is present, high-concentration oxygen and the most gentle support should be given until rigid bronchoscopy is available.
Meconium Aspirator:
        Take a tip from the Labor & Delivery room: ---literally! Confronted often with "Mec-Asp" in small newborns, this hard plastic whistle-hole endotracheal tube adapter allows it to be used on the suction line to suction the airway directly with a "large" tube then dismount the suction line and immediately connect to oxygen/ventilation in the usual fashion. NOT a bad trick for adults, either!


        Fiberoptic Laryngoscopy can often help make an anatomically difficult intubation possible.
        However, limitations include the general unavailability and lack of frequent use in emergency departments; cost; the small suction channel can't cope with large amounts of blood, secretions, or emesis; fragility; and difficulty in handling a larger ETT; and the practitioner's proficiency and experience.
        However, an ED should know where and by whom it can be brought at a moment's notice.
Stiff Neck:
May require indirect methods: e.g.
Awake Nasal ETT Updated URL Recovered from Archived Source,
Digital Intubation;
Retrograde Wire/Catheter Guided Intubation);
Special visualization aids such as Huffman Prism or Mirror Blades are unlikely to be available, but may be in the anesthesia workroom or ENT suite.
Fiber-Optic Laryngoscope.
Consider alternative airways such as Combi-tube, PTL, or LMA.
Immobilized Neck (fusion/spondylolisthesis/HALO/SOMI):
May require indirect methods:
        Awake Nasal ETT
        Digital Intubation;
        Retrograde Wire/Catheter Guided Intubation,
        Percutaneous Transtracheal Catheter Ventilation,
        Fiber-Optic Laryngoscope.
        Consider alternative airways such as Combi-tube, PTL, or LMA.


        "Cervical-spine injury is rare in nonjudicial hanging victims seen by paramedics and transported to the ED. Cerebral hypoxia, rather than spinal cord injury, is the probable cause of death and should be the primary concern in treatment of this patient population.  Following external stabilization of the neck, nasal or oral endotracheal intubation, when indicated, is the appropriate procedure for emergency airway management in hanging victims."    ["Emergency Airway Management in Hanging Victims" Tom Aufderheide, MD FACEP,  Charles Aprahamian, MD FACS, et. al.]

Carotid Blow-Out!:

        Tracheal hemoptysis from a large vessel in the irradiated neck of a laryngectomy patient with previous flap surgery. It was necessary to simultaneously provide high-flow oxygen, suction vigorously, place an endotracheal tube per stoma deeply, just proximal to the carina, to isolate the lower airways, and accept the lower blood pressure which perfused the patient but did not incite further bleeding. Hemostasis would need to be accomplished in the operating room for a case such as this.
Patient Is On The Floor:
        Many hospital-based airway managers are accustomed to having the patient always conveniently on a bed or table.
        If the patient is on the floor, as often encountered by paramedics, hospital-based providers may have little experience to guide them -especially if there is insufficient manpower to lift the patient or the patient's head is near the wall.
        The intubator in prone position facing the vertex of the supine patient and working on one's elbows may have tremendous leverage problems. Sometimes, another rescuer may need to lift the laryngoscope and jaw for him.
        If kneeling, the intubator having lifted the head and jaw with the laryngoscope may need to lean backwards to get the correct view down all axes of the airway.
        The intubator lying supine alongside the supine patient may be able to get good visualization and access.
Left lateral decubitus position for the intubator has been found better than kneeling position. (Adnetpmid.gif (982 bytes))

        Occasionally, it may be necessary to do the laryngoscopy from the anterior position facing the patient and lifting the jaw and visualizing the larynx by pulling the laryngoscope in the desired direction (out and down if patient is upright).
Portable Suction:
        We rely greatly, in the hospital, upon "wall suction" being present. Is there powered portable suction for critical patient intra-hospital transports? Updated URL Recovered from Archived Source
        Is there a manual suction device that can be used in a hallway or parking lot or during failure of piped-gasses and vacuum in a disaster?
Blown/Leaky Cuff or Cut Inflation Line:
Immediate Sellick's Maneuver of Cricoid Pressure.
        If stable situation, exchange tube, either by extubation and re-intubation or over a tube-exchanger device.
        If situation is unstable: Use syringe and needle to re-inflate pilot line and clamp below the needle; discard sharp. Blunt needles are available which can be used for this. Alternatively, insert and wedge-fit a large intravenous cannula into the lumen of the pilot line as a temporary repair; use an IV injection cap or a stopcock to seal the end. Monitor patient for recurrence of loss of cuff pressure and airway leak. Exchange of tube can be done when situation is stable.
        If situation is desperate: maintain Sellick's Maneuver of Cricoid Pressure; extubate; re-intubate.
Prolapsed Cuff on a tracheal tube:
        If a large-volume cuff prolapses beyond the tracheal tube (ETT or Tracheostomy) it may occlude the tube. (This was more commonly a problem with older designs of tubes with detachable cuffs rather than modern tubes with integral cuffs. It may occur when metal tracheostomy tubes are used with an inflatable cuff.) It will be impossible to pass a suction catheter beyond the obstruction. Immediately deflate the cuff to allow a partial airway. Change the tube "over" a Cook Tube Exchanger or a Ureteral Stent. Have a smaller tube available in case of swelling from manipulation.
        If obstruction does not clear by these means, extubate instantly with cricoid pressure, mask ventilate to good saturation, and reintubate.


        The classic method of oldentimes before the invention of the lighted laryngoscope.
        A tactile method of inserting the (double)gloved non-dominant hand into the mouth, while facing the patient from the foot end, and "walking" the fingers down the tongue, simultaneously drawing it and the jaw forward.
        When the epiglottis can be felt and pulled forward by the tip of the long or middle finger, the ETT is passed into the mouth from the side by the dominant hand and the tip of the tube is slid alongside and underneath the middle finger. The tube tip can additionally be reflected and "encouraged" anteriorly, by the index fingertip, towards the tracheal opening and onwards in-between the vocal cords. Carefully confirm placement.
        So long as the patient is sufficiently obtunded or free of gag-reflex to lessen the risk of biting, no other equipment is needed except the appropriately sized tube and the will and skill to use it.
        Useful for the extremely awkward position such as upright patients or wrecked cars.


        Relies upon the transillumination of soft tissues of the neck by a very bright bulb at the distal tip of the ETT supported on a malleable stylet carrier. As the light wand is passed per ora, note the brightness and light pattern transilluminating a cheek as it should be equivalent to that seen when the tube is endotracheally placed.
        Sometimes the room lights may need to be dimmed or (if outdoors or otherwise unable to control the level of ambient lighting) a blanket thrown over the heads of the intubator and the patient.
        Keeping the light strictly to the midline should help ensure successful intubation.
        If brighter on one side than the other it is off-center or in a piriform fossa.
        If uniformly dim and midline, it is esophageally placed.
        If center and anterior, it is tracheally placed.

Percutaneous Trans-tracheal Catheter Ventilation:

        Percutaneous Trans-tracheal Catheter Ventilation may sustain life and the positive pressure gasses exhausting retrograde through the upper airway may help minimize aspiration, and by bubbling help visualize the glottic opening for subsequent orotracheal intubation.  The cricothyroid membrane area is rapidly prepped with disinfectant. A ten milliliter syringe with two milliliters of 4% "Topical" Lidocaine is mounted on a large bore Intravenous Cannula (10, 12, 14, or 16 gauge X 2-3 inches) and the membrane is punctured at a 45 degree caudad  direction (towards the lungs and feet). Aspirate free air briskly to confirm the tracheal space (seen readily by bubbles in the Lidocaine and felt by the easy motion of the piston). Briskly inject (spray) the Lidocaine for anesthesia. Advance the cannula into the trachea.   Don't let go! There may be coughing! Demount the syringe while grasping and stabilizing the cannula firmly. Attach a jet insufflator, high-pressure (50 psig) Oxygen line and microvalve, or 15mm endotracheal tube connector for a 3.0mm endotracheal tube by which to ventilate the patient.

Ventilating the Crike:

        A 15mm endotracheal tube connector (fits all resuscitation equipment) from a 3mm endotracheal tube will fit into the large bore (10-12-14-16 gauge) intravenous cannula hub used for percutaneous transtracheal catheter ventilation . This is simpler and safer than the sometimes-recommended 3mm syringe barrel (without plunger) into which a 15mm endotracheal tube connector from a 7mm ETT (. . . but if you only have "adult size tubes . . .). However, airway resistance will be great with any such device.
        High pressure gas flows from special equipment will produce better ventilation than the usual respiratory bag. There is an excellent discussion of this in Ch. 15 "Manual Translaryngeal Jet Ventilation" by Ronald Stewart, MD in Emergency Airway Management.
        Allow sufficient pausing to permit exhalation through the small-bore cannula especially if the airway obstruction is total above the crike. Total expiratory obstruction is rare. With 100% oxygen source gas, adequate oxygen saturation can be gotten with slower rates of ventilation. Hypercapnia will increase without adequate exhalation/ventilation. Transtracheal catheter ventilation is temporizing if total obstruction exists. Its main role is in ventilating the non-intubatable but not totally obstructed patient.
        If chest deflation from elastic recoil is minimal, it may be desirable to apply cautious manual compression bilaterally to the thorax to assist exhalation; prompt conversion of the transtracheal catheter to a cricothyrotomy with an appropriate tracheostomy tube or a Cook© Critical Care "Melker Emergency Cricothyrotomy Catheter Set"™ " should occur so as to provide a wider-bore tube with less airway resistance.
Retrograde Wire/Catheter Guided:
        When all else fails, and little or no back-up help or equipment is available, Retrograde Guided Intubation may save the day, but should not wait upon the patient being moribund before it is used as it may take several minutes.
        The cricothyroid membrane area is rapidly prepped with disinfectant. A ten milliliter syringe with two milliliters of 4% "Topical" Lidocaine is mounted on a thin-wall Seldinger technique needle and the membrane is punctured at a 45 degree cephalad direction (towards the upper airway and head). Aspirate briskly to confirm the tracheal space. Briskly inject (spray) the Lidocaine for anesthesia. Demount the syringe while grasping and stabilizing the needle firmly, and pass a J-wire through the needle towards the pharynx. Do not lose control of the distal end of the J-wire.
        If there is a good deal of blood or vomitus near the upper airway, one may prefer to pass a long line or intra-cath: if the tip of a wire might not be seen, injecting air through the catheter might cause a visible bubble from the end thus allowing one to grasp the catheter with Magill's Forceps.
        Once the wire or catheter is retrieved from the pharynx and pulled out of the mouth (Make sure the distal end is NOT pulled into the trachea!), it may be threaded through the distal hole of the endotracheal tube and immediately OUT of the side-wall "Murphy eye". This will allow the tube to be slid down the wire in-between the vocal cords, the wire then to be pulled through, ventilation to be begun, and the tube secured.


        The Difficult Airway: Cricothyrotomy A ten minute VDO movie from American Society for Anesthesiology and the Anesthesia Patient Safety Foundation brought to you by Keith Ruskin, MD and his GASNet page at Yale.
Equipment or Devices that have been suggested for cricothyrotomy vary (it is best to be prepared with a plan and suitable supplies):
Cricothyroid membrane puncture with scalpel or knife then holding apart with the handle (spontaneously breathing).
Improvising a cannula from a pen barrel (spontaneously breathing).
Small cuffed endotracheal tube or tracheostomy cannula for open method above.
Percutaneous Transtracheal Catheter ventilation via largest available IV cannula that will fit.
Weiss Cricothyrotome Set, adult or pediatric.
"Pertrach" dilator set by Seldinger technique.
Tracheostomy set (as per your O.R.'s setup)


        HeliOx is a combination of Oxygen and Helium instead of the 78% Nitrogen which is in room air. Helium is a considerably less dense "lighter" gas (which is why helium filled balloons "float" -being bobbed upwards by the heavier O2/Nitrogen atmosphere pressing down upon it). This can make for more laminar flow and easier penetration of constricted small airways when used as a carrier gas for Oxygen. It is not respirable itself so oxygen concentration must never be less than 20%.

Gum Elastic Bougie:

        The Eschmann stylet or gum elastic bougie is a long rubber flexible device, over which an endotracheal tube can be threaded, with angled distal tip directed anteriorly that can be advanced blindly, perhaps with digital assistance,into the patient's oropharynx regardless of patient position and as the directed tip passes through the rima glottides the tip will palpably "bump" along the anterior tracheal rings as an additional clue to placement. The ETT can then be slid into the trachea and the bougie withdrawn. Proceed with customary confirmation of placement and ventilation.
A good description of this can be found in the article: "A Flexible Solution . . ."

Rigid Bronchoscopy:

        Best done in the operating room or specialized suite, by experienced specialist with adequate back-up resources, but capable of ventilating the patient and retrieval of the largest foreign bodies and providing pulmonary toilet less likely to be overcome by copious secretions than the fiberoptic scope.

Supplementary Tips

        When testing the inflatable cuff on the ETT prior to insertion, remember to "suck out" all the air and collapse it against the tube with sub-atmospheric pressure within (this will make it easier to view around the tube, less likely to damage the cuff on a tooth fragment, and to spot any leak which might cause the cuff to re-expand). Leave the syringe attached for instantaneous inflation with the fewest moves. Lubricate well with water-soluble surgical lubricant (and lubricate the stylet a bit, if there is time, as it might otherwise stick and drag on the withdrawal from the ETT).

        The first test breath to be auscultated for confirmation of placement should be listened for FIRST in the left axilla! Next the right axilla. Then the stomach. If all is well, one then has time to listen to the bases for adequacy of tidal volume. Left axilla first confirms ventilation and detects Right Mainstem Bronchus Intubation promptly. Right axilla then confirms right lung ventilation and compares for equality of breath sounds between the two lungs. Gastric auscultation then helps exclude esophageal placement. The symmetry of thoracic excursion, visible misting in the tube with exhalation, and listening/feeling for any ventilatory leak "around" the cuff should be noted along with these actions.

        If doing a blind nasal intubation of a spontaneously breathing patient, one can maximize the audibility and directionality of the airflow when a BAAM® whistle is not available (and avoid vomitus in one's own ear) by pulling off the head of a single-tube stethoscope and placing the end of the tubing a short way inside the ETT. Localize airflow, and advance between the cords during inspiration when the cords are apart.

        If Cocaine is not available "in the room", or an alternative agent is needed, consider a 50% mixture of 4% Topical Lidocaine and Oxymetazoline nasal spray to achieve local anesthesia and decongestion/vasoconstriction.

        One way of effectively distributing an anesthetic/decongestant spray is to modify the squeeze-bulb atomizer by substituting an oxygen line controlled with an interposed thumbhole port from a suction catheter (O2 line->port->rubber tubing to atomizer stem). One then gets a controlled steady powered blast spray and supplemental oxygenation.

        When restocking the intubation tray, the most commonly forgotten items are:
                            the syringe for inflating the tube;
                            the stylet,
                            tape or suitable fixation device.

        The intubator will often neglect to turn off the light on the laryngoscope blade. If the handle is kept in intubating orientation while removing, the blade can be pressed against the mattress as it is laid down shutting it off. This can be done without any extra effort or letting go of the tube. If not done, the assistant should check the handle as soon as the tube is secured.

        When the patient is transported, remember to bring or send the appropriate mask in case of accidental extubation. If an anesthesia bag is used to hand-ventilate, remember to bring or send a self-refilling bag-valve-mask resuscitation bag so as to remain capable of ventilating with room air in case of loss of compressed gas or delay due to stuck elevator.


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Web Resources for Airway Management:

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Practice Guidelines for Management of the Difficult Airway:
An Updated Report by the American Society of Anesthesiologists
Task Force on Management of the Difficult Airway
Anesthesiology 2003; 98(5):1269-1277

Address reprint requests to the American Society of Anesthesiologists: 520 North Northwest Highway, Park Ridge, Illinois 60068-2573.
Individual Practice Guidelines may be obtained at no cost through the Journal Web site, www.anesthesiology.org

Newly released is the ASA's "systematically developed set of recommendations based on analysis of the current literature and a synthesis of expert opinion."
It replaces the 1993 report. It includes data published since 1992 and recommends a wider range of management techniques.
This expert document will be, as were the previous versions, a cornerstone in examining an appropriate standard of care.


Each of the articles in this box has an Updated URL Recovered from Archived Source
(i.e., is no longer presented or maintained on the web by the original author/host)

star-small.gif (929 bytes)Emergency Airway Management Guide: Vanderbilt University Dept. of Anesthesiology's excellent nine-part guide includes:

Evaluation of the Emergency Airway Controlled Ventilation Direct Laryngoscopy and Endotracheal Intubation
Indirect Tracheal Intubation Flexible Fiberoptic Laryngoscopy and Endotracheal Intubation Confirmation of Endotracheal Intubation
Use of Pharmacologic Agents Management of the Pediatric Airway Evaluation of a Child with Inspiratory Stridor


star-small.gif (929 bytes) Airways for Anyone by Peter WJ Harrigan B. Med (Hons) FANZCA FFICANZCA  or pdf.gif (130 bytes).pdf version
from University of Pittsburgh's Multidisciplinary Critical Care Medicine program website.
star-small.gif (929 bytes) logo-TheAirwaySite.jpg (20339 bytes) "The Airway Site" from The Faculty of the
"National Emergency Airway Management Course"
star-small.gif (929 bytes) logo-CapnographyDotCom.gif (3640 bytes) Capnography.com
An educational, animated website by
Bhavani Shankar Kodali MD
Assistant Professor, Harvard Medical School
Brigham and Women's Hospital, Boston, MA
sign_new-bluegold.gif (1043 bytes)star-small.gif (929 bytes) Dr. Magboul's Airway Page Comprehensive site from University of Iowa Anesthesiology faculty member
sign_new-bluegold.gif (1043 bytes)flag-Australia-vsmall.gif (908 bytes) How To Assist With Adult Intubation "everything you wanted to know about assisting with an adult intubation... but were afraid to ask" from Australia's logo-ImpactEDemergencydept-Australia.jpg (117290 bytes) Good nursing introduction to process and organization of emergency intubation.
star-small.gif (929 bytes)

Interactive Airway Device Tutorials from University of Florida Dept. of Anesthesiology


The Difficult Airway Aphorisms: Random Insights into Airway Management From the Battle Weary
Updated URL Recovered from Archived Source
from EDUCATIONAL SYNOPSES IN ANESTHESIOLOGY by Dr. D. John Doyle of University of Toronto
These aphorisms were composed with hospital anesthesia practice in mind but the preceptual wisdom should be borne in mind whenever approaching a difficult airway situation and in planning before any sedated procedure

star-small.gif (929 bytes)John's Airway/Respiratory InfoCenter Updated URL Recovered from Archived Source from Dr. D. John Doyle of University of Toronto

Airway Glossary Updated URL Recovered from Archived Source from Dr. D. John Doyle of University of Toronto

Review of Rapid Sequence Drug-Assisted Intubation from Univ. Iowa's Virtual Hospital

Time-Sequence Graphic Table for Rapid Sequence Drug-Assisted Intubation from Univ. Iowa's Virtual Hospital

Airway Management of the Trauma Victim from Trauma.org in UK

Initial Trauma Assessment - The Anaesthetist's Role by Ian Zunder, MD, FRCPC
Department of Anaesthesia, Ottawa Civic Hospital, University of Ottawa, Ottawa from the annual Winterlude Symposia

Medical Conditions With Airway Implications from D. John Doyle MD PhD FRCPC, Department of Anaesthesia, The Toronto Hospital, Toronto, Canada

star-small.gif (929 bytes)The UCSD Virtual Difficult Airway Cart from the University of California San Diego Department of Anesthesiology: ---review the items and their use, study the algorithms . . .

The ASA Difficult Airway Algorithm as presented by UCSD

Anesthesia for the Morbidly Obese Patient - Anesthetic Management of the Patient with Sleep Apnea
from Educational Synopses in Anesthesiology & Critical Care Medicine

Intubation Techniques and Equipment; the Difficult Airway by Rajesh P. Haridas, MBChB, FANZCA, a chapter of the Virtual Anaesthesia Textbook

An Overview of Blind Orotracheal Intubation by Rajesh P. Haridas, MBChB, FANZCA
from Educational Synopses in Anesthesiology & Critical Care Medicine

Brief Intubation Video from Greater Houston Anesthesiology

Brief LMA Video from Greater Houston Anesthesiology

Brief VDO Movie of LMA Insertion by Dr. Allan Palmer of Queensland University GASBONE for Queensland Rural Doctors

Airway Management and Difficult Intubation,10 minute VDO movie, by Dr. Frank Maloney on GASBONE for Queensland Rural Doctors

Palmer J: Awake Fiberoptic Intubation. An Electronic Online Multimedia Streaming Video. The Internet Journal of Anesthesiology 1998; Vol2N1: http://www.ispub.com/journals/IJA/Vol2N1/fibervdo.htm ; Published January 1, 1998; Last Updated January 1, 1998.

Patel R: Use of Percutaneous Transtracheal Jet Ventilation (PTJV) during Difficult Airway Management. The Internet Journal of Emergency and Intensive Care Medicine 1999; Vol3 N1: http://www.ispub.com/journals/IJEICM/Vol3N1/ptjv.htm. Published January 28, 1999; Last Updated January 28, 1999.

The Laryngeal Mask Airway Page from Dr. D. John Doyle of University of Toronto

Using The Laryngeal Mask Airway An instructional module from the inventor, Dr. Brain, for The Cleveland Clinic Foundation

Laryngeal Mask Airway: Uses in Anesthesiology by Mark Pinosky, MD, Charleston, SC
from the online edition of Southern Medical Journal, June 1996

The LMA in Failed Intubation from The Cleveland Clinic Foundation

Vadhera RB: The Use of LMA in Newborn Resucitation. The Internet Journal of Anesthesiology 1997; Vol1 N4: http://www.ispub.com/journals/IJA/Vol1N4/lma.htm . Published October 1, 1997; Last Updated October 1, 1997.

Nasotracheal Intubation Complications from Univ. of Wisconsin's Anesthesia Topics
Transtracheal Catheter Ventilation from Univ. of Wisconsin's Anesthesia Topics

Oesophageal Detector Devices by Rajesh P. Haridas, MBChB, FANZCA from World Anaesthesia Online

Prehospital Intubation and the role of the Oesophageal Detector Device
by Greg Gibson and Greg Sassella, MICA Paramedics from Australia -A web article from MERGInet

The Esophageal Detector Device: Summary of the current articles in the literature. Compiled by Tim Wolfe, M.D. from the Ambu USA site

Infant vs. Adult Airway from Univ. of Wisconsin's Anesthesia Topics
Infant Airway  from Univ. of Wisconsin's Anesthesia Topics
Acute Epiglottitis from Univ. of Wisconsin's Anesthesia Topics
Apneic Oxygenation from Univ. of Wisconsin's Anesthesia Topics
High-Frequency Jet Ventilation from Univ. of Wisconsin's Anesthesia Topics
Pressure-Support Ventilation from Univ. of Wisconsin's Anesthesia Topics

Fiberoptic Bronchoscope Guided Intubation from The Cleveland Clinic Foundation

star-small.gif (929 bytes)Aids To Fiberoptic Intubation by Dr. T.V. Srinivasan, MD Dept. of Anaesthesia & ICU, Ahmadi Hospital, Ahmadi, Kuwait

Review Article: Intraoperative Awareness: A Continuing Clinical Problem
from Educational Synopses in Anesthesiology & Critical Care Medicine
{Remember: the patient is always listening!}

"Anesthesia for the Non-Anesthetist" Anaesthetic Peri-Operative Considerations
from the Department of Anaesthesia at Orillia Soldiers' Memorial Hospital.

FAQ for Anesthesia Patients from Greater Houston Anesthesiology

Airway Atlas color endoscopic images of airway pathology

Pediatric Airway Obstruction Page Michael Rothschild, MD's atlas of airway disease images

Laerdal Introduces the TrachLight from Respiratory Therapy Society of Ontario

Insertion of the Laerdal TrachLight from The Cleveland Clinic Foundation

Society for Airway Management website still evolving;
PO BOX A3982, Chicago, Illinois, 60690-3982 USA
SAM telephone number: (773) 834-3171 SAM fax number: (773) 834-3166

Clinical Practice Guideline: Management of Airway Emergencies; the American Assn. for Respiratory Care

ACUTE SEVERE ASTHMA Status Asthmaticus - in the ER and the OR by Jon Hooper, MD, FRCPC, Department of Anaesthesia, Ottawa Civic Hospital, University of Ottawa, Ottawa from Winterlude 95

Neonatal Resuscitation: the NRP guidelines by Robert D. Elliott, MD, FRCPC, Department of Anaesthesia, Ottawa General Hospital, University of Ottawa, Ottawa from Winterlude 95

Updated URL Recovered from Archived Source Trauma Cases from Harborview Medical Center
Acute Airway Obstruction From Sloughed Pseudomembrane After Inhalational Steam Injury [Archived URL]
Peter B. Hathaway 1; Eric J. Stern 1; Richard C. Harruff 2; David M. Heimbach 3
Depts. of Radiology 1 (Box 359728), Pathology 2, and Surgery 3 Harborview Medical Center, University of Washington, Seattle WA 98104

OTOLARYNGOLOGIC EMERGENCIES [ from Otorhinolaryngology Core Curriculum Syllabus; Baylor College of Medicine - Ben Taub Hospital] Airway Obstruction, Inspired or Ingested Foreign Bodies, Sore Throat or Difficulty Swallowing, Epistaxis, Ear Complaints, Head and Neck Infections, Airway and Facial Trauma

Foreign Bodies [ from the Otorhinolaryngology Grand Rounds Archives at Baylor College of Medicine]

Foreign Body Aspiration [ from the Otorhinolaryngology Grand Rounds Archives at Baylor College of Medicine]
Blunt Trauma to the Larynx [ from the Otorhinolaryngology Grand Rounds Archives at Baylor College of Medicine] Complications of Tracheotomy [ from the Otorhinolaryngology Grand Rounds Archives at Baylor College of Medicine]

Changing Fresh Tracheostomy Tubes [ from D. John Doyle, MD at Univ. Toronto]

Bibliography on the Airway and C-spine Injuries Prepared by Richard J. Sperry, MD University of Utah, Salt Lake City Copyright © 1996 SNACC All Rights Reserved (posted on GASNet)

Clinical References and Clinical Article Summaries [from O-Two Systems, Inc.] a bibliography of important articles in resuscitation

Emergency tracheal intubation of patients lying supine on the ground: influence of operator body position.
Adnet F, Cydulka RK, Lapandry C. Can J Anaesth 1998 Mar;45(3):266-9 pmid.gif (982 bytes)9579267

The Paediatric Airway: A Practical Approach to Airway Management Online PowerPoint presentation by a UK ENT specialist.

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For further reading . . .

The Airway: Emergency Management /edited by Robert H. Dailey, MD, et. al.;1992; St. Louis, MO; Mosby-Year Book, Inc.; ISBN 0-801601270-5

"Ch. 11 Advanced Airway Support" by Daniel F. Danzl, MD, in Emergency Medicine: A Comprehensive Study Guide; Fourth Edition; Judith E. Tintinalli, MD, MS, Editor-In-Chief; 1996; McGraw-Hill; New York;

"Airway Management", Section 2 Resuscitation Chapter 7, by Ian R. Morris, MD, in Emergency Medicine: Concepts and Clinical Practice, Volume One, by Peter Rosen, MD, Editor-In-Chief, and Roger M. Barkin, MD, MPH, Senior Edition, Third Edition, © 1992, Mosby Year-Book, Inc., St. Louis, MO

"Ch. 78 Conventional Airway Access" by Donna A. Costello, DO, Howard S. Smith, MD, and Philip D. Lumb, MBBSM FCCM, pp. 698-712, in Textbook of Critical Care, Third Edition, by Stephen M. Ayres, MD, FCCM, Senior Editor, ©1995, W. B. Saunders, Philadelphia, PA

"Ch. 80 Surgical Airway, Cricothyroidotomy, and Tracheotomy: Procedures, Complications, and Outcome" by Rade B. Vukmir, MD, Ake Grenvik, MD, PhD, Carl-Eric Lindholm, MD, PhD, pp. 724-734, in Textbook of Critical Care, Third Edition, by Stephen M. Ayres, MD, FCCM, Senior Editor, ©1995, W. B. Saunders, Philadelphia, PA

"Principles of Airway Management", by Steven J. White, MD, FACEP, and Paul M. Paris, MD, FACEP, pp. 18-27, in Current Practice of Emergency Medicine; Second Edition, by Michael L. Callaham, MD, FACEP, ©1991, B. C. Decker, Inc., Philadelphia, PA

"Endotracheal Intubation" by Ronald D. Stewart, MD, FACEP, pp27-38, in Current Practice of Emergency Medicine; Second Edition, by Michael L. Callaham, MD, FACEP, ©1991, B. C. Decker, Inc., Philadelphia, PA

"Rapid Induction Anesthesia For Emergency Intubation" by Henry Schumaker, MD, and Richard Glaser, MD, pp. 39-44, in Current Practice of Emergency Medicine; Second Edition, by Michael L. Callaham, MD, FACEP, ©1991, B. C. Decker, Inc., Philadelphia, PA

"Percutaneous Transtracheal Ventilation and Cricothyrotomy" by Ernest Ruiz, MD, pp. 44-47, in Current Practice of Emergency Medicine; Second Edition, by Michael L. Callaham, MD, FACEP, ©1991, B. C. Decker, Inc., Philadelphia, PA

"Emergency Airway Management Procedures" by Joseph E. Clinton, MD, and Ernest Ruiz, MD, in Clinical Procedures In Emergency Medicine" by James R. Roberts, MD, and Jerris R. Hedges, MD, pp. 2-29, ©1985, W. B. Saunders, Philadelphia, PA

"Ch. 11 Airway Management and Ventilation", pp. 205-283, in Paramedic Emergency Care: Third Edition; by Bryan E. Bledsoe, DO, EMT-P, Robert S. Porter, MA, NREMT-P, and Bruce R. Shade, EMT-P, ©1997, Prentice-Hall Inc., Upper Saddle River, NJ

"Section 4: Airway Management Skills" and "Section 5: Positive Pressure Ventilation And Assisted Ventilation Skills" in Comprehensive Guide To Pre-Hospital Skills: A Skills Manual For ---EMT-BASIC, EMT-INTERMEDIATE,EMT-PARAMEDIC BY Alexander M. Butman, BA, D.Sc., REMT-P, Scott W. Martin, BS, REMT-P, Richard W. Vomacka, BA, REMT-P, Norman E. McSwain, Jr., FACS, REMT-P ©1995 Emergency Training, Akron, OH ISBN Number:0-940432-09-9

"The Upper and Lower Airway and Associated Structures", pp. 2-47, in Clinical Anatomy for Emergency Medicine" by Richard S. Snell, MD, PhD, and Mark S. Smith, MD, ©1993, Mosby-Year Book, Inc., St. Louis, MO

"Difficult Intubations: Tricks to Remember" from "Intubation For The Primary Care Physician" Emergency Medicine; January 15. 1990; "eighth article in an 11-part series that began in the April 30, 1989 issue and includes: Anatomy; Preintubation Evaluation; Equipment; Oral Intubation; Common Errors; Tube Placement; Intubating a Child; Difficult Intubations; Nasal Techniques; Management; and Complications"

"Rapid-Sequence Intubation of the Pediatric Patient" Gerardi MJ, Sacchetti AD, Cantor RM, Santamaria JP, Gausche M, Lucid W, Foltin GL (The Pediatric Emergency Medicine Committee of the American College of Emergency Physicians): Annals of Emergency Medicine July 1996;28:55-74 pmid.gif (982 bytes) 8669740 © American College of Emergency Physicians [editor's note: a lucid and cogent exposition of the RSI rationale and process, and a review of sedation, NMB, and other agents and techniques] c.f., also, related editorial: "Rapid-Sequence Intubation Comes of Age" by Ron M. Walls, MD, on pp79-81

"Emergency Airway Management in Hanging Victims" Tom Aufderheide, MD FACEP,  Charles Aprahamian, MD FACS, et. al., Annals of Emergency Medicine November 1994;24:5 pp879-884  pmid.gif (982 bytes) 7978561 ©American College of Emergency Physicians

"Life-threatening airway obstruction from rattlesnake bite to the tongue.Gerkin R, Sergent KC, Curry SC, Vance M, Nielsen DR, Kazan A Ann Emerg Med 1987 Jul;16(7):813-816  pmid.gif (982 bytes) 3592340 ©American College of Emergency Physicians

Antony Nocera, MB, BS; "A Flexible Solution for Emergency Intubation Difficulties"; Annals of Emergency Medicine 27:5 pp665-667May 1996 pmid.gif (982 bytes) 8629792 © American College of Emergency Physicians"

Bozeman WP, Hexter D, Liang HK, Kelen GD: Esophageal Detector Device Versus Detection of End-Tidal Carbon Dioxide level in Emergency Intubation. Annals of Emergency Medicine May 1996;27:595-599. pmid.gif (982 bytes) 8629780 ©American College of Emergency Physicians

"Laryngoscopic Intubation From The Front"; William E. Gandy, JD, EMT-P EMS Educator. Tyler Junior College, Tyler, TX  [http://www.tyler.cc.tx.us/emmt/]   Personal Communication 4/24/98



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