Arguably the most challenging situation for a practitioner is when a patient wearing a full-face helmet needs oxygenation and ventilation but the helmet cannot be removed easily. Many circumstances can make helmet removal difficult or impossible. Examples of such situations include patients with foreign objects penetrating the helmet and embedded in the skull and patients in whom removal of the helmet causes them extreme pain or distress, or individuals trapped in confined spaces where the helmet cannot be removed (eg, race car). A systematic assessment of the airway management options for this patient will show that bag-mask-ventilation is impossible because the helmet's face shield obscures the mouth and chin. Similarly, insertion of an EGD is practically impossible because access to the mouth is also limited. The two remaining options are (1) surgical airway using a cricothyrotomy or (2) nasotracheal intubation. Rapid assessment of the surgical landmarks relevant to cricothyrotomy, either percutaneous or open, is essential since this part of the patient's airway is usually unobstructed by the helmet or face shield. Securing the airway by a nasotracheal route is relatively simple and potentially useful and lifesaving. Airway practitioners familiar with nasotracheal intubation techniques should review the contraindications to this approach, such as evidence of basal skull fracture, prior to proceeding. Blind nasal intubation in a spontaneously breathing patient has a reasonable success rate by experienced practitioners. A recent report showed that blind nasal intubating technique has a 90% success rate for prehospital trauma patients requiring an endotracheal tube.9,10 However, the success of blind nasotracheal intubation is limited by practitioner familiarity. A flexible lightwand, such as the Trachlight™, loaded on a nasotracheal tube can be effectively used to achieve endotracheal intubation in a patient wearing a full-face helmet.11 In this technique, transtracheal illumination using the lightwand indirectly confirms proper placement of the nasotracheal tube.12 If blood is present in the airway, the potential for a false passage in the airway makes a blind technique relatively contraindicated. Using a flexible bronchoscope can be a helpful guide, especially in situations where blind techniques are contraindicated, but its efficacy may be limited by the presence of blood or secretions in the airway. Flexible endoscopic intubation can be performed with the patient awake and the nasopharyngeal mucosa topically anesthetized or with the patient under general anesthesia and muscle relaxed. The risks of each approach should be considered in the context of the patient's comorbidities and the practitioner's familiarity with the techniques.
Airway practitioners are strongly advised to consider a "double set up" plan that includes both a primary intubation approach (eg, a light-guided nasotracheal intubation, flexible bronchoscope, etc) and a secondary back up surgical approach for the patient wearing a full-face helmet that cannot be removed. Since the patient's neck is almost always accessible regardless of the type of helmet worn, a double set up facilitates prompt airway control via a surgical access in case the primary plan is unsuccessful. Two separate equipment trays should be prepared: the first contains all the equipment needed for oral or nasotracheal access; the second tray contains all the instruments needed for a surgical airway. Having a second skilled practitioner available who is familiar with surgical airway access is ideal. Prior to initiating the airway intervention, the patient should be optimally positioned, the neck should be prepped, and the airway management team should agree on clear trigger points that identify when the primary approach has failed and the secondary approach is to be undertaken (ie, surgical airway).