The Difficult Airway
Dr. David Snow
What is a more appropriate start to an EM blog than an airway discussion? Let’s start with the basics and expand as we progress through the year.
A 23 year-old female presents by EMS. A friend called EMS, and the patient is unable to provide any history given her decreased mental status. There is a strong smell of ethanol on her breath.
On exam, her respirations are coarse and somewhat sonorous. She has no obvious exam findings of trauma. She does respond to painful stimuli.
What do I do?
Rules of the Road
Failure to Oxygenate
Failure to maintain adequate oxygenation, despite supplemental oxygen, in a condition that is not reversible is a cause for intubation. Possible reversible causes include pulmonary edema or other conditions where the use of noninvasive positive pressure ventilation (NIPPV) can help overcome the pathophysiology at hand. Opioid overdose or something similar is another reversible cause.
Failure to Ventilate
Same as the above. Worsening hypercapnia that does not respond to other measures will eventually require intubation. Altered mental status from a post-ictal state and severe COPD exacerbations are two common causes for ventilatory failure and subsequent hypercapnia requiring intubation.
This rule pertains to the patient that at this moment in time does not break any of the above 3 rules. However, such is the nature of their presenting problem, you know they will progress to the point where this will happen, and intubation early is a smart move. Good examples of this are angioedema patients who are not responding to standard treatments, yet in front of you are protecting their airway and are adequately oxygenating and ventilating – but you know that if the observed swelling or respiratory distress is allowed to continue this will be a much harder patient to intubate.