Beyond the Basics: Airway MANAGEMENT

CEU Review Form Airway MANAGEMENT (PDF)Valid until March 6, 2007

An experienced real estate agent will tell you that, when purchasing a home, there are three important things to consider: location, location, location. An experienced EMS provider will tell you that, when treating a patient, the three most important considerations are: airway, airway, airway.

     As our EMS profession grows in number of providers, calls for service and increasing technology, the reality is that the most basic of assessments-proper assessment of the airway-is still critical to the outcome and survivability of any patient we encounter.

     Shortly after 9:30 p.m., you and your partner are dispatched to the report of a man stabbed with a knife at a local convenience store. After the police have secured the scene, they direct you to the patient-the 46-year-old male store owner, who is supine on the ground with an approximately 2" laceration and puncture wound to the right side of his leg, near the medial aspect of his thigh. The patient is conscious and in obvious respiratory distress (pale, diaphoretic and a respiratory rate of approximately 36). In a raspy voice he asks you, "Am I going to die?"

     You know his airway is intact because he is talking to you, so you quickly cover his wound with a gloved hand, and your partner applies high-flow oxygen through a non-rebreather.

     Situations like this play out every day. Providers must ask themselves: Is the scene truly safe? Should I cover the open wound with a gloved hand? Should I quickly activate the trauma center? There are a hundred more questions and considerations for care. We learn ways to quickly make these decisions. We are often taught that if the patient is talking, the airway is intact. This may be true, but the more difficult and often neglected question is, "Will it remain that way?"

     This patient has several critical needs, but one that may be overlooked is the raspy voice. Indeed, his voice tells us that he is able to breathe and that he is conscious. But what about the raspy sound? Is this normal, or will his airway soon become a problem? Will you gamble that the patient is pale, diaphoretic and tachypneic because of his possible blood loss, or will you more carefully examine his airway to see if there is another stab wound in his neck? The raspy voice may be the biggest initial clue you have to alert you to a life-threatening problem.

     Early in our EMS careers we are taught the ABCs of prehospital care: airway, breathing and circulation. We recite it like a mantra in continuing education classes, but it helps keep our priorities in perspective. We can continue to use the ABCs to evaluate the airway. The ABCs of airway are simply assessment, basics and control.

Assessment
     Airway assessment is not as simple as talking to your patient or asking the examiner, "How's her airway?". It involves all of the ABCs. Since we lack x-ray vision to visualize all of the airway's structures, we must evaluate the result of airway problems: their effect on breathing. To thoroughly assess a patient's airway, we must assess:

     Adequacy of breathing

     Blockages

     Concerns that set off our alarms.

     Adequacy of the airway can be measured through evaluation of the depth and effort of breathing. Many providers fail to properly assess depth of breathing because it is best assessed by exposing the chest. Retractions and intercostal muscle use may be hidden by clothing, and heavy layers may prevent any assessment at all. Remember, you cannot treat what you can't see. Expose the chest in an appropriate setting, if possible, for evaluation, and re-cover the patient afterwards. Using trauma shears is an option, but careful removal (or unbuttoning) of clothes may allow for adequate assessment without destroying the patient's property. Additionally, assess the effort of breathing by noting the way in which patients position themselves. Are they lying on their backs, feet crossed, with the appearance of a vacationer on a beach, or are they sitting bolt upright, straining to get every last ounce of oxygen? Pursed lips, tripod position, arched shoulders and retractions should be ominous signs.