Chapter 16. Airway Management of an Unconscious Patient Who Remains Trapped Inside the Vehicle Following a Motor Vehicle Collision

A 23-year-old driver is involved in a motor vehicle crash (MVC) in which her car has collided with an oncoming vehicle. On arrival at the scene, the emergency medical services (EMS) field team estimates a prolonged extrication time and difficult airway problem, and calls for EMS physician-on-call back-up. Upon arriving at the scene, you note that she appears to be unconscious inside the vehicle and is not making effective respiratory efforts. She is slumped back against her seat.

16.2.1 According to the Advanced Trauma Life Support (ATLS) Guidelines, What Are the Immediate Issues that Need to Be Addressed?

The prehospital environment can be an unpredictable and unstable environment for the patient and the EMS practitioner. Thus, prior to the initiation of resuscitation protocols, scene safety must be assessed and assured. Assessment and management of the airway, breathing, and then circulation (ABCs) follows Advanced Trauma Life Support Guidelines (ATLS).1 After scene safety, for the critically injured patient, airway management remains the greatest priority and challenge. In this unconscious patient, rapid extrication from the vehicle is unlikely, so airway assessment and management must be performed immediately while the patient is still in the vehicle.

In this patient, the practitioner must assume that the patient has suffered a severe traumatic brain injury (TBI). Oxygenation and ventilation in the setting of severe TBI is of utmost importance in initiating treatment as prolonged hypoxia and hypercapnia are associated with increased morbidity and mortality. Associated injuries are likely in this patient: cervical spine injury; cardiothoracic injuries such as pneumothorax, hemothorax, flail chest, cardiopulmonary contusions, and cardiac tamponade; as well as intrabdominal injuries. Once the airway is adequately managed, the EMS team will need to assess the patient for these injuries, while recognizing that a complete assessment and definitive intervention will require expeditious transport to adequate in-hospital facilities.

16.2.2 How Does This Prehospital Setting Affect Your Management of This Patient?

Field management of this patient's airway is second only to scene safety considerations. The scenario described is an example of a worst-case situation and the field environment will have a significant impact on the options and interventions available. The practitioner will not be able to make the same judgments or carry out the same assessments possible in a controlled hospital environment. In this context, the practitioner will have to choose the optimal method of airway management in this patient while considering other options, should the primary attempt fail. While prehospital intubation has traditionally been used as the definitive airway in the field environment, there is growing evidence that it may be associated with no patient benefit at best2 and possibly an increased risk of adverse patient outcomes3,4 at worst. If tracheal intubation is found to be difficult or impossible, or beyond the skill set of the responder, the use of alternative airway techniques, including the extraglottic devices (EGDs), should be considered.

16.2.3 What Are the Indications for Airway Management in This Patient?

Life-threatening ventilatory insufficiency will lead to cardiorespiratory arrest if not corrected promptly—particularly in the context of a severe TBI and elevated ICP. Furthermore, airway management is indicated in this patient in order to protect from hypoxia and aspiration.

16.2.4 Are There Any Special Considerations in This Case?

There are several important considerations which should guide the prehospital practitioner in managing this patient's airway. These include: a critically injured patient and the need to immediately secure the airway, TBI, limited patient access, and limited resources. The fact that the patient is trapped and the confines of the vehicle restrictive will not allow for controlled intubation conditions. Direct laryngoscopy (DL) is likely contraindicated in such surroundings in the immediate management of this patient's airway. Furthermore, Mort et al, found a positive correlation between the number of laryngoscopic intubation attempts (≤2 vs >2) and complications, including hypoxemia, regurgitation of gastric contents, aspiration, bradycardia, and cardiac arrest.5 These data suggest that EMS practitioner should limit the number of intubation attempts in this patient—and perhaps avoid attempting laryngoscopic intubation in this patient and alternative methods would be indicated. Airway interventions should be instituted quickly and would include other airway adjuncts if initial intubation attempts fail. Securing an airway must be undertaken in a planned and expeditious manner.

If the patient is obtunded but still has intact airway reflexes (eg, gag reflex), any attempt at airway manipulation may lead to biting, gagging, and the vomiting of gastric contents. Airway reflexes will also make more difficult attempt at airway intervention.

16.2.5 How Would You Alleviate the Airway Obstruction?

Several simple maneuvers can be used to alleviate an airway obstruction. These include a chin lift, jaw thrust, head tilt, and tongue pull. Some of these simple steps may involve significant movement of the C-spine (see Chapter 15). Although a jaw thrust, or pulling the tongue forward, is traditionally felt to be associated with the least cervical movement, cadaver studies have shown it is still associated with some C-spine movement and should be performed carefully.6 However, in this emergency situation, in which the failure to oxygenate and ventilate this patient may result in greater risk to hypoxic brain injury and perhaps death, the practitioner must weigh the risk of cervical spine movement against the risk of failure to provide oxygenation and ventilation.

Application of a face mask with oxygen supplementation should be performed at a minimum. In the absence of adequate respiratory effort, ventilation and oxygenation must be provided to the patient immediately by bag-mask-ventilation (either one person or two person), if possible, while planning for a more definitive airway. An oropharyngeal airway may help to alleviate airway obstruction.

16.2.6 How Would You Assess the Patient's Airway? Are Traditional Means of Airway Assessment Valid in the Unconscious Patient?

Several airway measurements exist as tools to predict a difficult laryngoscopy (see Chapter 1). Unfortunately, these assessment tools are not useful in the prehospital environment in which on-scene factors (patient positioning, poor patient access, smoke, fumes, fire, and environmental hazards) as well as uncooperative or unconscious patients may prevent EMS practitioner from performing these assessments.

The overall appearance of this patient should first be assessed. Specifically, on-site practitioner should assess the patient for signs of inadequate ventilation, as manifested by signs of gasping, use of accessory muscles, indrawing, cyanosis, and so on. Airway evaluation in this patient should then proceed to a search for airway trauma and signs of injury to the head and neck.

The practitioner should assume airway management will be difficult and should be ready to use alternative airways techniques, should early intubation attempts fail.

16.3.1 Is This Patient Likely to Be Difficult to Oxygenate? Why?

Airway management must be initiated prior to extrication. BMV may be made more difficult if there is blood or teeth, or foreign bodies in the airway. If the patient is upright or there is limited access to the face, oxygenation will be a challenging task and the practitioner may find two-person BMV (see Chapter 7 for details) will facilitate ventilation/oxygenation in this patient. While the acronym "MOANS" (see Section 1.6.1) may be useful to predict difficulties with BMV in conscious cooperative patients, it is not useful for this patient. The effect of trauma to the head and neck on BMV can be unpredictable, but does not preclude an initial attempt at BMV to oxygenate the patient. It is also reasonable to use an extraglottic device (EGD), such as the laryngeal mask airway (LMA), if the BMV fails. Unfortunately, the effectiveness of ventilating a patient using the LMA may be equally unreliable following facial trauma.

Blind airway techniques should be avoided in patients with a facial trauma as it may be associated with injuries to the airway and a potentially distorted anatomy. However, in the presence of hypoxemia, coupled with limited resources, a blind or nonvisual airway technique may be considered to ensure ventilation and oxygenation, provided that it is performed cautiously by a skilled practitioner.

16.3.2 What Are Your Airway Options in This Patient?

Managing the airway of this patient will be challenging due to the critical injuries sustained by this patient and the unpredictable environment. The options that should be considered by the initial EMS practitioners will depend on their skills and level of training. To avoid significant complications, advanced airway techniques, including alternative techniques, should be attempted only by skilled and experienced EMS practitioners. Practitioners with basic airway skills should use basic airway maneuvers, including jaw thrust and tongue pull. Jaw thrust maneuvers should be used with caution because of the risk of cervical spine injury. However, to minimize the risk of hypoxemia or hypoventilation, it would be reasonable to perform a gentle jaw thrust to improve ventilation/oxygenation when a chin-lift does not appear to clear the obstructed airway. Practitioners with appropriate airway training might, in addition to the above maneuvers, consider the use of EGDs, such as the various types of LMA devices (LMA Classic™, intubating LMA, LMA ProSeal™), Laryngeal Tubes, and Combitube™ among others. The availability of these devices in various EMS organizations may determine the specific EGD used.

Practitioners with advanced airway training may consider the use of endotracheal intubation, ranging from DL to the use of the intubating LMA, lightwand (eg, Trachlight™), and surgical cricothyrotomy. Endotracheal intubation may be fraught with risks and complications in this patient, particularly with practitioners who do not routinely perform the procedure. These complications including esophageal intubation, aspiration, hypoxemia add further trauma to the airway.

Regardless of the level of airway training, multiple intubation attempts should be avoided if initial attempts at intubation are unsuccessful, as repeated attempts will increase the risk of hypoxemia and mortality.

16.3.3 What Is the Role of the Extraglottic Devices in Managing the Airway of This Patient?

There are several extraglottic devices (EGDs) which can be used as rescue airways. These include the LMA and its variants (such as the LMA Fastrach™ and the LMA ProSeal™), Combitube™, Laryngeal Tube (King LT™), and others.

Insertion and use of the LMA is described in Chapter 12. The LMA and its variants are advantageous in this patient because it can be inserted while facing the patient who may be upright and difficult to access and may provide an effective rescue airway to oxygenate the patient. While there are many other EGDs that can be used in this setting, most practitioners are familiar with the LMA and perhaps, it should be the device of choice. The LMA is also useful because it can provide a conduit for subsequent endotracheal intubation (LMA Classic™ and LMA Fastrach™).

Although intubation using the LMA to guide the endotracheal tube (ETT) into the trachea can be performed using either the LMA Classic™ or the LMA Fastrach™ (intubating LMA), it is much easier to advance the ETT through the LMA Fastrach™. (See Table 16-1 for appropriate ETT sizes.)

The LMA Fastrach™ is designed with a rigid handle to facilitate its insertion. When correctly positioned, the LMA Fastrach™ is designed to direct the ETT into the trachea. Reported intubation success rates using the LMA Fastrach™ range from 82% to 99.3%.8 Although the LMA Fastrach™ comes with a specifically designed silicone-wire-reinforced tracheal tube, a recent report found no difference in the success rates in intubation through the LMA Fastrach™ when the silicone-wire ETT was compared to a warmed standard polyvinyl chloride ETT.9 However, the necessity of warming an ETT, especially in the prehospital environment, makes it a less attractive option.

When used together with the LMA Fastrach™, the Trachlight™ (see Section 12.4.3) has been shown to facilitate confirmation of tracheal placement of the ETT and improve the success rate of tube placement.10 There is a growing consensus that the LMA Fastrach™ may be a useful airway alternative in the prehospital environment due to its rapid learning curve,11 high success rate of insertion, and its ability to ventilate and oxygenate the patient, as well as to facilitate intubation.

The Combitube™ (see Section 12.6) is a double-lumen EGD which can be easily inserted as a rescue device in this patient. Several reports suggested that it can play an important role in trauma airway management.12-15 Its correct use depends on determining its position either in the esophagus (>90% of insertions) or the trachea and ventilating the patient via the correct lumen. Incorrect use can lead to significant complications, including insufflation of the stomach with aspiration, esophageal and pharyngeal trauma, and subsequent rupture.15 Its use is contraindicated in the presence of esophageal or pharyngeal injuries.11

The Laryngeal Tube (see Section 12.7) is a single-lumen EGD device with a distal and proximal cuff. In between the two cuffs are ventilation ports which allow for oxygenation of the patient. The Laryngeal Tube (LT) has been shown to be easily inserted with minimal airway trauma. However, there are few peer-reviewed studies examining the role of the LT in the trauma patient. Some studies have suggested inexperienced prehospital practitioners have a 78% to 100% success rate of insertion in anesthetized patients.16 In prehospital cardiac arrest patients, the LT was successfully inserted in 83% of patients.17 Like other EGDs, the LT is not designed to protect against aspiration, so similar precautions to other EGDs should be considered. However, the recent introduction of the single-use Laryngeal Tube with suction and drainage option (LTS-D) may provide protection against aspiration.18 While it appears that LT is an effective EGD, its role in trauma airways remains to be determined.

16.4.1 Discuss the Role of EGDs in the Trauma Patient

EGDs are gaining popularity in managing the airway of the trauma patient when the trachea cannot be intubated.19-22 Martin et al examined the use of the LMA in the prehospital environment; the authors reported a success rate of 94% in trauma patients.21 All successful insertions were performed in 10 seconds or less. The authors investigated the effectiveness of the LMA in providing adequate oxygenation and ventilation in these patients and found that, during transport, patient oxygen saturations ranged from 97% to 100% while the end-tidal CO2 ranged from 24 to 35 mm Hg.21 These data support a role for the LMA, and other EGDs (although most studies have only examined the role of LMAs), as tools for oxygenation and ventilation in trauma patients when tracheal intubation in the field was unsuccessful.

To address the issue of aspiration with EGDs, multiple devices have been developed with alternate channels that would allow for drainage of regurgitated gastric contents.23 The LMA ProSeal™ (see Section 12.5 for details) contains a drainage tube that extends into the upper esophagus at the distal end of the device.23 Multiple case reports suggest that the LMA ProSeal™ is effective24,25 at minimizing, although not eliminating, aspiration risk.26,27

The Combitube™ also has the potential to protect the airway from aspiration of gastric contents. Using dye within the oropharynx, Mercer recently showed that the Combitube™ could protect the airway in most anesthetized patients.28 However, tracheal soiling was seen in 7% (2/27) of the studied patients.28 Similarly, using a pH probe in the trachea, Hagberg et al29 reported evidence of low pH in the trachea in 1 of 25 anesthetized patients (4%) using a Combitube™, suggesting possible microaspiration of acidic gastric contents.

Recently, dual-lumen laryngeal tubes with suction and drainage (LTS-D and LTS-II) have been introduced. While these devices may allow easy ventilation and aspiration protection,18 large clinical studies are needed to assess their effectiveness in doing so.

In summary, while these EGDs are effective rescue devices to provide oxygenation and ventilation in trauma patients, and may play an important role in providing oxygenation and ventilation in patients with difficult or impossible intubation, they do not ensure protection against the risk of aspiration of gastric contents.

16.4.2 What Are Your Concerns with Transporting This Patient with an EGD as an Airway?

EGDs are effective devices for ventilation; however, there are a few considerations to keep in mind during transport.

First, these devices cannot ensure complete protection of the airway against the risks of aspiration, although many studies have not reported a significant incidence.21,22,30 There have been case reports of the successful use of the LMA ProSeal™ and LMA Supreme™ as a rescue airway in trauma,7 suggesting that it may play a role in the prehospital environment. At this time, the lack of well-designed studies of EGDs in the trauma setting would suggest supporting their use as rescue devices only if endotracheal intubation fails.

A second concern regarding the use of EGDs in the prehospital management of the trauma patient relates to the risk of malpositioning during transport. Any change in the positioning of the EGD may impair its ability to provide effective oxygenation and ventilation and the practitioner must continuously monitor the positioning and effectiveness of the EGD during transport. The application of cervical collars to maintain in-line cervical stabilization may also cause the EGDs to shift or cause airway obstruction during transport.22

16.4.3 What Are Your Options for Endotracheal Intubation in This Patient?

Laryngoscopic intubation may be difficult until the patient is extricated from the vehicle. Even then, the condition of the patient in the field environment may be adverse to the successful placement of an ETT under DL. In the clinical situation in which the patient cannot be removed from the vehicle, the options for endotracheal intubation include lightwand-guided intubation, digital intubation, and intubation through an LMA or the LMA Fastrach™. However, it should be noted that techniques not requiring direct visualization, such as the lightwand, increase the potential for airway trauma. Thus, intubation with either direct laryngoscopy (if possible) or using the LMA Fastrach™ is preferable to attempts at intubation with the lightwand.

16.4.4 Discuss the Pros and Cons of Lightwand (Trachlight) Intubation in This Patient

Light-guided intubation using a lightwand has been shown to be an effective and safe technique for both oral and nasal-tracheal intubation.31-33 The technique of intubation using the lightwand (Trachlight™) has been described in Chapter 11.34,35

Because of its limitations as a nonvisualizing technique, the lightwand should be reserved for situations in which alternative airway techniques are difficult or impossible. These include limited mouth opening and patient factors that would make surgical cricothyrotomy impossible (eg, lack of equipment, trauma to the anterior neck, making impossible to identify landmark, etc). In the absence of these factors, other airway management techniques would be more advantageous than the lightwand, including direct laryngoscopy and the use of EGDs (+/- intubation).32,33,36

The disadvantages of the lightwand in this patient include possibility of a traumatized airway, and ambient lighting may make the use of a lightwand difficult. Since we are unable to rule out a traumatic airway in this patient, the use of the lightwand may lead to delays in securing the airway and may further increase the risk of hypoxemia, morbidity, and mortality.

16.4.5 Digital Intubation

Digital intubation (or tactile orotracheal intubation) involves the insertion of an ETT into the trachea using the fingers. It should be performed only by trained practitioners. Digital-guided intubation has been described previously (see Chapter 11). It is a safe and effective technique for airway management in the prehospital setting in an unconscious patient, requiring minimal equipment and patient access.37,38

While facing the patient, the clinician pulls the patient's tongue forward using the dominant hand. The nondominant hand is then inserted into the oropharynx where the epiglottis can be palpated and lifted superiorly using the long finger. An Eschmann Tracheal Introducer (ETI) (if available) can then be inserted into the airway with the dominant hand. The Eschmann Tracheal Introducer is then guided anteriorly into the trachea with the index finger of the nondominant hand. Confirmation of tracheal placement of the ETI can be done in the usual manner (eg, tracheal clicks and the hold up). The ETT can then be advanced over the ETI and into the trachea, employing the nondominant hand to guide the ETT over the tongue into the trachea. The ETI is then removed and positioning of the ETT in the trachea is confirmed using auscultation and end-tidal CO2. If an ETI is not available, an ETT with stylet can be advanced into the airway and guided into the trachea (see Section 11.4). Digital intubation can also be performed using the lightwand in lieu of the ETI. This allows the practitioner to confirm placement using tactile and visual cues.

There are relatively few studies examining the role of digital intubation in the management of a patient's airway. Stewart reported that digital intubation is a simple and useful airway technique in the prehospital environment because it can be performed with minimal head and neck movement and with a cervical collar in place.38 The presence of blood or secretions in the airway does not seem to influence its success. Similarly, Hardwick and Bluhm, in their series, report successful intubation in 58 out of 66 patients in the prehospital setting.37

Digital intubation is an effective airway technique that, while possible, should be reserved only for those skilled in this technique. It cannot be used in patients with intact airway reflexes.

16.4.7 Would Nasotracheal Intubation Be Suitable for This Patient?

Blind nasal intubation would not be the first choice for airway management in this patient because of potential basal skull fracture and lack of respiratory efforts. However, in the event that the patient's condition is deteriorating rapidly, and multiple attempts at the airway have been made, it may be reasonable to consider the blind nasal technique while concurrently preparing for a surgical cricothyrotomy if the practitioner is skilled with these techniques.

16.4.8 Surgical Cricothyrotomy

If the airway cannot be secured (either by endotracheal intubation or with the use of an EGD), and ventilation is unsuccessful or inadequate, securing the airway using a surgical technique is indicated. Delays in proceeding to a surgical airway following a series of failed attempts at airway control, is an important cause of morbidity and mortality. Surgical airways, such as surgical cricothyrotomy (SC), should be performed only by those familiar with the techniques. Studies in prehospital airway management have reported success rates of 82% to 100% when performed by trained paramedics, nurses, or physicians. Complication rates vary from 0% to 27%.39 Details of performing SC are described in Chapter 13. The practitioner should be aware that obese patients, or those with abnormal anatomy (eg, hematoma, trauma to the neck, previous surgery, and radiation), might make identifying the cricothyroid membrane difficult. SC can be performed using either the open or Seldinger technique. To facilitate SC, there are a number of cricothyrotomy kits available (eg, Cook Critical Care, Bloomington, IN). If possible, a cuffed cricothyrotomy tube should be used to ensure effective ventilation following its placement.

While SC may not be performed often in the prehospital environment, there is evidence that it can be performed, with reasonable success, should prehospital responders be appropriately trained.39-41 In their retrospective review of SC performed by paramedics, Fortune et al found that paramedics who were trained in SC were able to perform the technique with 64% of patients arriving in the emergency department with acceptable SC airways.41 A further 16% required minor manipulation in the emergency department.

If cricothyrotomy kits are not available, SC can be performed with a scalpel, an Eschmann Tracheal Introducer (gum elastic bougie) and an endotracheal tube.42,43 In these reports, the authors describe the insertion of an Eschmann Tracheal Introducer (ETI) following a skin and cricothyroid membrane incision. The ETT is then guided over the ETI and acts as its own dilator of the cricothyroid membrane. The advantage of this technique is that it does not require a cricothyrotomy kit, has only three steps, and can be done quickly in an emergency. Similar to all airway management techniques, this three-step cricothyrotomy technique needs to be taught prior to its use in the field.

16.4.9 What Would Your Overall Approach Be in the Management of This Patient's Airway?

The management of this patient's airway must take into consideration the safety of the scene, the skills of the practitioner, the equipment available, the critical nature of this patient's injuries, and the urgency of establishing an airway. Emergency medical systems (EMS) can vary significantly in both structure and quality of care. North American EMS organizations are paramedic-based systems while other EMS organizations incorporate physicians (often anesthesiologists) and other health professionals. The variability between skill levels of prehospital practitioners precludes a generic algorithm appropriate for all responders. Rather, it would be more appropriate to have protocols based on the skill level of the practitioner.17

Initial attempts at airway management, appropriate for responders of all skill levels, should involve simple maneuvers which may alleviate the obstructed airway or facilitate further airway interventions. This includes a jaw thrust, tongue pull, and/or insertion of an oropharyngeal airway (OPA). Chin lifts may be considered necessary, but one should proceed with caution and recognize the potential impact of cervical spine movement in a patient with a high risk of cervical spine injury.

If the patient initiates any respiratory effort with these maneuvers, attempts at supporting the patient's airway while extrication proceeds may be sufficient—particularly if the responder has training only in basic airway management. Insufficient ventilation in this situation may necessitate assistance with BMV. This may require two-person BMV to ensure adequate delivered volumes.

Responders possessing training beyond basic skills may continue with BMV or consider the use of other adjuncts. The LMA Laryngeal Tube™, or Combitube™ are the most commonly used prehospital airway alternatives. The skill levels required to ensure proper insertion and adequate ventilation are variable. The insertion success rates to allow adequate ventilation for the LMA Classic™ may vary between 64% and 100% when inserted by respiratory therapists and EMS providers.17,44,45 The LMA Fastrach™ may be a useful alternative because of its ease of insertion, high success rate, and ability to ventilate as well as facilitate intubation.17 In their observational study of prehospital intubations by paramedics using either the intubating LMA or direct laryngoscopy, McCall et al46 found that the rate of successful intubation of unconscious patients was 88% with the intubating LMA and 63% with DL. Nakazawa et al8 demonstrated successful intubations between 82% and 99.3% with the intubating LMA. Overall success rates, including those requiring more than one attempt, were not statistically different at 91% for DL and 92% with the intubating LMA.46 In a simulation of a difficult airway, Reeves et al47 examined the rates of successful insertion of the intubating LMA by ambulance officers, physicians with intubating experience, and physicians without intubation experience. Most importantly, they found that 100% of patients were successfully ventilated with the intubating LMA. The respective failure rates of intubation (not ventilation) in the groups were 7% (ambulance officers with intubating experience), 20% (physicians with intubating experience), and 16% (physicians without intubating experience).47 While the study by Reeves et al involved only a small group of participants, the results are consistent with other studies which suggest that success insertion rates are high with the intubating LMA in individuals with varying levels of airway management skills.17 In this situation, ventilation and oxygenation may be all that is needed until the patient can be extricated and transported to hospital. In the event that tracheal intubation is needed, the intubating LMA may facilitate the ETT placement.

The LMA ProSeal™ (see Section 12.5) is a variant of the LMA with the potential ability to passively drain gastric contents via its esophageal vent.48 There have been case reports of the drainage tube allowing for drainage of gastric contents during active vomiting.25,49 Conversely, there have also been case reports of aspiration despite the use of the LMA ProSeal™.48

The use of the combitube™ (see Section 12.6) in prehospital care has been well described.17 Its insertion does require training and, thus, its use should be reserved for the trained practitioner. Esophagus placement occurs 95% of the time with the remaining 5% resulting in translaryngeal placement. Successful insertion and ventilation ranges from 79% to 82.4%.17

The practitioner with advanced training in airway management may feel comfortable using additional airway techniques beyond those already described (maneuvers to relieve airway obstruction, EGDs). Additional options, reserved for practitioners with advanced skills in airway management, include digital intubation and surgical cricothyroidotomy as described earlier.

As with all airway management techniques, successful ventilation and oxygenation should be confirmed using colorimetry or capnography.

Prehospital airway management of an unconscious, apneic patient trapped in a vehicle is one of the most challenging situations for airway practitioners. Options in airway management are generally limited. The selection of an airway technique must depend on the field conditions, patient's condition, available resources, and the skills of the practitioner.

The focus of the practitioner should be on maintaining oxygenation and ventilation until the patient can be extricated to facilitate further assessment and management. The approach should begin with basic airway techniques including jaw thrust, chin lift, and the provision of oxygen via BMV. Practitioners with more advanced training can employ alternative airways including the EGDs, or may attempt intubation. Multiple attempts should be avoided for fear of increasing the risk of hypoxemia, hypercarbia, airway trauma, and mortality. If intubation is deemed appropriate, alternative intubating techniques such as digital intubation, intubating LMAs may be considered, but only by practitioners with advanced airway skills. Others with less experience or training should focus on basic airways skills and getting further assistance. Surgical cricothyrotomy may be necessary if oxygenation and ventilation is inadequate despite other techniques. It can be performed with either commercially available cricothyrotomy kits or, in emergency situations; the three-step technique can be used.