Gentle downward pressure applied to the cricoid cartilage (Sellick's maneuver) at the onset of induction and

paralysis has been historically advocated to limit the potential for aspiration. A growing body of literature has begun to

question the utility of this maneuver as it not only fails to

prevent aspiration but can limit adequate visualization of

the vocal cords and impair successful insertion of the ETT. If

cricoid pressure is applied, release inlmediately if the patient

begins to vomit to prevent secondary esophageal rupture.

� Difficult Airway Adjuncts

Multiple devices have been designed to assist with the

management of difficult airways. Laryngeal mask airways

AIRWAY MANAGEMENT

Figure 1 1-5. Schematic demonstrati ng use

of bougie.

(LMA) conform to the natural curvature of the oropharynx and are designed for blind insertion into the supraglottic region. Proper insertion creates an airtight seal over

the larynx, allowing for mechanical ventilation. LMA

insertion does not prevent aspiration, though, and is not

considered a definitive airway.

Introducer bougies are very useful in patients whose

vocal cords cannot be adequately visualized. They are

essentially long flexible rubber sty lets with a distal curve at

their tip, which, when blindly inserted along the inferior

margin of the epiglottis, will naturally angle upward into

the larynx and through the vocal cords. Successful endotracheal placement can be detected as the tip of the bougie

skips along the tracheal rings. The ETT is then inserted

blindly over the bougie and into the airway (Figure 1 1-5).

Cricothyrotomy is performed by making a percutane ­

ous incision in the cricothyroid membrane through which

a tracheostomy or small ETT can be placed (Figure 1 1-6).

This can be a life-saving intervention in the crashing

patient when less invasive techniques to secure the airway

have failed. Common indications include massive facial

trauma and angioedema. Cricothyrotomy is contraindi ­

cated in children <8 years of age and should be replaced

with needle cricothyrotomy.

Additional difficult airway adjuncts include blind nasatracheal intubation, lighted stylets, Combitubes, fiberoptic

intubation, retrograde wire-guided tracheal intubation,

and percutaneous translaryngeal ventilation.

DISPOSITION

Admit all patients who require airway management to an

intensive care unit setting.

Figure 1 1-6. Cricothyrotomy. A. An 11 blade

scalpel is used to cut the cricothyroid membrane. B. A

skin hook opens the incision and lifts the thyroid

carti lage su periorly so that the tracheostomy tube or

ETT can be inserted into the ai rway. (Reprinted with

permission from Bai l itz J, Bokhari F, Scaletta TA, et al.

Emergent Management of Trauma. 3rd ed. New York:

McGraw-Hill Education, 201 1 .)

SUGGESTED READINGS

Hedayati T, Ross C, Nasr N. Airway procedures. Rapid sequence

intubation. In: Simon RR, Ross CR, Bowman SH, Wakim PE.

Cook County Manual of Emergency Procedures. 1 st ed.

Philadelphia, PA: Lippincott Williams & Wilkins, 201 2, pp.

14-2 1.