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A 70-year-old depressed man presents after attempted suicide by shooting himself with a handgun held under his jaw. He is seated upright and leaning forward when paramedics arrive on the scene and refuses to lie supine due to facial bleeding. He is kept in position to optimize airway patency and is expeditiously transported to the nearest emergency department (ED). The patient presents to the ED in tripod position with obvious bleeding from his mouth. His anterior mandible is missing, and he is holding a non-rebreather oxygen mask in front of his face. His oxygen saturation is 95% and has been stable during transport. Vital signs include a pulse of 85 beats per minute, a blood pressure of 175/90 mmHg, a respiratory rate of 22 breaths per minute, and a temperature of 37°C. Upon initial examination (Figure 28.1), he has ongoing oral hemorrhage and is completely missing his anterior mandible. The patient is awake and has a GCS of 15. In light of his injuries, he is kept upright on the gurney in anticipation of tracheal intubation (for airway protection).


The patient in the emergency department sitting with a non-rebreather oxygen mask.


What Are the Airway Evaluation Considerations for This Patient?

This patient presents with multiple clinical issues that may influence his airway management.1 The missing anterior mandible is a dramatic presentation, but standard trauma management principles apply.2,3 His airway does require management for airway protection and the anticipated clinical course. However, this is not a “crash” intubation situation (because his oxygen saturation is >90% and he is stable). Therefore, a rapid evaluation of the airway for anticipated difficulty is possible.4 If this were a “crash” scenario (e.g., vital signs become unstable or patient becomes hypoxemic), an emergency cricothyrotomy might be the most appropriate initial approach.2,4

The presence of orofacial disruption will likely hinder face-mask ventilation (FMV) due to a poor mask seal and attempts at FMV may create subcutaneous emphysema further distorting tissues. Similarly, with the associated hemorrhage, soft-tissue edema, and the presence of foreign bodies (teeth, clots, etc.), the use of an extraglottic device (EGD) may be difficult. Laryngoscopy will likely be complicated by the presence of blood, tissue edema, and possible airway disruption. However, the absence of mandibular resistance might actually make visualization easier. Additionally, it is always wise to consider cervical spine injury in the setting of head trauma, but this case is special. Maintenance of strict cervical spine precautions in this instance, such as lying the patient supine or placing the patient in a cervical collar, could result in aspiration and obstruction of the airway.3 In this instance, maintaining the patient in a position of relative comfort in an upright, sitting position allows the patient to ...

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