Three Cardinal Sins in Airway Management

-If your patient can't breathe, nothing else matters.1

When a lawyer calls me to review records in an EMS case, there's a high probability that it involves airway mismanagement.

Though there are no national statistics available, the majority of EMS lawsuits I have dealt with have been based in airway mistakes. In this article, I've identified three cardinal sins in airway management that will result in losing your patient and a visit to the local courthouse as defendant in a lawsuit.

Cardinal Sin No. 1: Failure to Ventilate

The thing that kills is not failure to intubate-it's failure to ventilate.

In one sense, basic rescuers have the best of all possible worlds. They have only oral and nasal airways, the BVM and possibly the dual lumen airway to work with. If you know how to use those devices, you can ventilate most patients.

But isn't endotracheal intubation the gold standard of airway management? Not if you can't intubate. Relying solely upon a higher and more complex method of airway management can give false security and lead to failure of airway control unless the practitioner falls back on basic skills.

"Evidence presented for the development of the American Heart Association's Emergency Cardiac Care Guidelines 2000 documented serious complications associated with attempted tracheal intubations by inadequately trained, inexperienced, or poorly supervised providers. Tracheal intubation may be no more effective than bag-mask ventilation and may even be harmful."2

Recently, I spoke to a paramedic friend about airway management, and I asked her what backup airway devices her service carries. "None," she said. When I recovered from my initial shock, I asked why. "Because our medical director says we ought to go to surgery and practice intubation until we know how to do it," she answered.

A fine and noble goal to be sure. Trouble is, sometime in your career you'll encounter a patient whom you cannot intubate. Even emergency department physicians and anesthesiologists have failures.

I have watched people attempt intubation until their patient turned purple, yet they never backed off or asked that the patient be ventilated. When ego gets in the way, patients die.

So, before embarking on an airway mission, ask yourself whether or not you can ventilate any patient you have to take care of. A surprising percentage of people I see taking advanced airway courses cannot, for several reasons.

They can't make a seal around the patient's mouth and nose with the BVM and fail to realize they are not getting adequate tidal volume into the patient.

They don't realize that people's faces have infinitely variable shapes and they must constantly reassess BVM position, hand position, patient's head and neck position, chest rise and fall and oxygen saturation, and that they should ask another rescuer to listen for breath sounds.

They forget that the best way to ventilate with the BVM is with three rescuers: one to hold the mask in place and keep the jaw extended, one to squeeze the bag and a third to apply Sellick's maneuver.

Cardinal Sin No. 2: Failure to Recognize a Failed Esophageal Intubation and Correct It

Most airway-related lawsuits I have been involved with focused on incorrect and unrecognized tube placement. Failure to recognize an esophageal intubation is an unforgivable sin; placing an endotracheal tube in the esophagus is not. If you do that, detect it, correct it and keep your patient ventilated, fine. Remember, it is ventilation, not intubation, that counts.

Misplaced endotracheal tubes happen in many ways. The difficult intubation is probably the No. 1 cause. Usually, the tube was never in the trachea to begin with. When you can't see the cords, it's tempting to put a little more bend on the end of the tube and poke it in, hoping it will go in the right place. Then, you fool yourself into thinking you're hearing breath sounds when you're not. After you're in the ambulance, it's virtually impossible to hear breath sounds.