Rapid airway assessment in emergencies

What “rapid airway assessment” is (and why it matters)

• A fast bedside check to answer 3 questions: (1) Is the airway currently threatened? (2) Can I oxygenate/ventilate now? (3) What is my safest plan to secure the airway (and what are my backups)?
• In emergencies, the priority is oxygenation (getting oxygen into the lungs), not “getting the tube in”.
• Aim to identify: obstruction, aspiration risk, predicted difficulty with mask ventilation/supraglottic airway (SGA)/intubation, and whether a front-of-neck airway might be needed.
• Reassess repeatedly: airway status can change quickly (vomit, swelling, reduced consciousness, fatigue).

Immediate first look: “Is this airway safe right now?”

• Listen: stridor (high-pitched noise on breathing in), gurgling, snoring, silence (very concerning).
• Look: work of breathing, use of accessory muscles, tracheal tug, cyanosis, agitation/confusion, inability to speak in full sentences.
• Feel: air movement at mouth/nose; check for facial/neck swelling, surgical emphysema, tenderness/trauma.
• Check consciousness: reduced GCS increases risk of obstruction and aspiration.
• If in doubt, treat as threatened airway and call for senior help early.

Rapid ABC approach (airway-focused)

• A: Airway patency and protection (can they maintain their own airway? are they at risk of aspiration?).
• B: Breathing effectiveness (rate, effort, chest movement, SpO2, end-tidal CO2 if available).
• C: Circulation matters for airway decisions: shock/low BP increases risk with induction drugs; consider resuscitation before intubation if possible.
• Always start oxygen immediately: high-flow oxygen via non-rebreathe mask; consider nasal cannulae for apnoeic oxygenation if preparing to intubate.

Simple bedside predictors (quick and useful)

• Mouth opening: <3 finger breadths suggests harder laryngoscopy and SGA insertion.
• Neck movement: limited extension (arthritis, collars, trauma) makes laryngoscopy harder.
• Mallampati (if cooperative): higher grade suggests less space; do not delay urgent care to obtain it.
• Jaw protrusion / mandibular space: receding jaw, small chin can predict difficulty.
• Obesity, beard, edentulous, facial trauma: often harder mask ventilation.
• Previous anaesthetic record: any prior difficult airway, awake intubation, or front-of-neck airway is highly relevant.

Common emergency airway scenarios and what to look for

• Reduced consciousness (overdose, head injury, seizures): snoring/obstruction, vomiting/aspiration risk; consider airway adjuncts and early definitive airway if not protecting airway.
• Upper airway obstruction (anaphylaxis, angioedema, infection, tumour): stridor, swelling, voice change; avoid repeated attempts—call ENT/anaesthetics early and prepare for front-of-neck access.
• Trauma: blood, broken teeth, facial fractures; assume full stomach; consider C-spine precautions; suction is essential.
• Asthma/COPD: may be hard to ventilate; focus on oxygenation, bronchodilators, avoid dynamic hyperinflation; intubation can be high risk—get senior help.
• GI bleed/vomiting: high aspiration risk; suction-ready, head-up if possible, consider rapid sequence induction (RSI) with experienced operator.
• Burns/inhalational injury: soot, hoarseness, facial burns; swelling can worsen—early senior review and consider early intubation.

Practical “first actions” that buy time

• Position: head-up (ramped) for obese/respiratory distress; “sniffing” position if no C-spine concern; jaw thrust if obstructed.
• Airway adjuncts: oropharyngeal airway (OPA) for unconscious patients; nasopharyngeal airway (NPA) if mouth won’t open (avoid if suspected base of skull fracture).
• Suction: have it on and in your hand early (blood/vomit is common).
• Two-person mask ventilation: one person holds mask with two hands (jaw thrust), the other squeezes bag; use PEEP valve if available.
• If mask ventilation is poor: add OPA/NPA, reposition, check seal, consider SGA early rather than struggling.

Choosing a plan quickly: Plan A–D mindset

• Plan A: best first attempt at securing airway (often video laryngoscopy if available, with optimal positioning and suction).
• Plan B: oxygenation with SGA if intubation fails or is not immediately possible.
• Plan C: face-mask ventilation (two-person) if SGA fails; wake the patient if feasible (often not in true emergencies).
• Plan D: emergency front-of-neck airway (eFONA) if you cannot oxygenate (CICO: can’t intubate, can’t oxygenate).
• Limit attempts: repeated laryngoscopy worsens swelling/bleeding and reduces oxygen reserves; change something each attempt (operator, device, position, blade, bougie).

Calling for help and team setup (non-technical skills)

• Call early: senior anaesthetist, ODP/assistant, ENT (if obstruction), ICU, and emergency team as appropriate.
• Allocate roles: airway operator, assistant (suction, cricoid if used, drugs), monitoring, runner, documentation/timekeeper.
• Say the plan out loud: “Plan A is…, if fail then Plan B…, if can’t oxygenate then Plan D…”.
• Prepare essential kit: oxygen, suction, bag-mask, airway adjuncts, SGA, laryngoscope/video, bougie, ETT sizes, capnography, front-of-neck kit.

Minimum monitoring and confirmation

• Use full monitoring whenever possible: ECG, SpO2, non-invasive BP, capnography.
• Capnography (end-tidal CO2) is the best way to confirm tracheal intubation and ongoing ventilation; absence should prompt immediate reassessment.
• If capnography is unreliable (low flow states), use multiple signs: chest rise, auscultation, misting, improving oxygenation—but treat uncertainty as oesophageal until proven otherwise.
• After securing airway: reassess ventilation pressures, breath sounds, tube depth, and haemodynamics; consider gastric decompression if needed.