Chapter 6

A 50-year-old man is in the waiting room of the emergency department (ED) awaiting evaluation for several days of hematuria. He has a remote history of prostate cancer. Suddenly, the man falls to the floor, becomes unresponsive, and has a generalized, tonic-clonic seizure. The emergency physician and paramedic on duty are summoned by the triage nurse. Intravenous (IV) access is established and the seizure is halted with multiple doses of intravenous lorazepam totaling 12 mg. Unfortunately, the patient is extremely somnolent and the emergency physician is concerned that he is at risk for airway obstruction, apnea, and aspiration. The decision to intubate the trachea is made.

The obtunded patient is positioned on a stretcher and monitors are applied. Evaluation of airway anatomy and ease of intubation reveal no significant predictors of difficulty. The physician elects to proceed with a rapid-sequence intubation (RSI). Direct laryngoscopy using a Macintosh #3 blade proves difficult, with two failed attempts by the physician. Bag-mask-ventilation (BMV) is performed between attempts and the patient's oxygen saturation never falls below 95%. On the third attempt, direct laryngoscopic intubation is successful with the aid of an Eschmann Tracheal Introducer (commonly known as the gum-elastic bougie) after establishing a partial (Cormack/Lehane Grade 2) view of the glottis.

The patient is sedated and transported to the CT scanner. CT scan is unremarkable. Collateral history reveals a history of heavy alcohol abuse, although the patient had recently decided to "quit drinking" and had been abstinent for 48 hours. A presumed diagnosis of alcohol withdrawal seizure is made and sedation is weaned. Three hours postintubation, the patient is noted to be awake, cooperative, and increasingly agitated by the tracheal tube. Extubation is performed without incident and supplemental oxygen is applied by facemask. Several minutes later the bedside nurse summons the physician as the patient is having increasing difficulty in breathing with labored, noisy respirations. Moments later, the patient loses consciousness and becomes apneic and cyanotic.

The emergency physician immediately attempts tracheal intubation via direct laryngoscopy but fails due to a completely obstructed upper airway secondary to a massive tongue hematoma. The hematoma is presumed to be as a result of his earlier seizure. Help is summoned and a Code Blue is called.

The fundamental goals of airway management are the maintenance of adequate ventilation, oxygenation, and protection from aspiration of foreign materials. In the majority of clinical settings, these three goals are achieved in tandem, usually via orotracheal intubation using a conventional laryngoscope. As the location, skill set of the practitioner, and the devices available (ie, the "context") change, the practitioner must be prepared to modify his or her approach and employ different techniques as appropriate. The provision of oxygenation, by whatever method possible, is ultimately the task that takes precedence over all others, particularly in emergency situations.

### 6.2.1 What Is Context-Sensitive Airway Management?

The concept of "context-sensitive" airway management ...

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