FIFTH EDITION THE WALLS MANUAL OF EMERGENCY AIRWAY MANAGEMENT EDITOR-IN-CHIEF Calvin A Brown III, MD Assistant Professor of Emergency Medicine Director of Faculty Affairs Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts ASSOCIATE EDITORS John C Sakles, MD Professor Department of Emergency Medicine University of Arizona College of Medicine Tucson, Arizona Nathan W Mick, MD, FACEP Associate Professor Department of Emergency Medicine Tufts University School of Medicine Associate Chief Department of Emergency Medicine Maine Medical Center Portland, Maine Acquisitions Editor: Sharon Zinner Developmental Editor: Ashley Fischer Editorial Coordinator: Maria M McAvey, Annette Ferran Production Project Manager: Kim Cox Design Coordinator: Stephen Druding Manufacturing Coordinator: Beth Welsh Marketing Manager: Rachel Mante Leung Prepress Vendor: S4Carlisle Publishing Services Fifth edition Copyright © 2018 Wolters Kluwer Copyright © 2012 (4th edition) LWW; 2008 (3rd edition) LWW; 2004 (2nd edition) LWW; 2000 (1 st edition) LWW All rights reserved This book is protected by copyright No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services) 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Names: Brown, Calvin A., III, editor | Sakles, John C., editor | Mick, Nathan W., editor Title: The Walls manual of emergency airway management / editor-in-chief, Calvin A Brown III, MD, assistant professor of Emergency Medicine, Director of Faculty Affairs, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts ; associate editors, John C Sakles, MD, professor, Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona, Nathan W Mick, MD, associate professor, Tufts University School of Medicine, associate chief, Department of Emergency Medicine, Maine Medical Center, Portland, Maine Other titles: Manual of emergency airway management Description: Fifth edition | Philadelphia : Wolters Kluwer, [2018] | Revised edition of: Manual of emergency airway management / editors, Ron Walls, Michael Murphy, 4th edition, 2012 | Includes bibliographical references and index Identifiers: LCCN 2017012521 | ISBN 9781496351968 (paperback) Subjects: LCSH: Respiratory emergencies—Handbooks, manuals, etc | Respiratory intensive care—Handbooks, manuals, etc | Airway (Medicine)—Handbooks, manuals, etc | BISAC: MEDICAL / Emergency Medicine Classification: LCC RC735.R48 M36 2018 | DDC 616.2/00425—dc23 LC record available at https://lccn.loc.gov/2017012521 ISBN-13: 978-1-4963-5199-9 Cataloging-in-Publication data available on request from the Publisher This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient The publisher does not provide medical advice or guidance and this work is merely a reference tool Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work LWW.com Dedication This book is dedicated to four pioneers in emergency medicine (left to right): Drs Robert Schneider, Ron Walls, Mike Murphy and Robert Luten Their vision and tireless devotion to education led to the creation of The Difficult Airway Course and this comprehensive text of emergency airway management They have defined and refined safe, evidence-based airway management practices for generations of emergency providers and, in the process, have saved countless lives.” Preface I t is with pride and immense joy that we present this fifth edition of The Walls Manual of Emergency Airway Management, from here on known simply as “The Walls Manual.” This book has been extensively updated from cover to cover and expanded with exciting new chapters It contains the latest in evidence-based approaches to airway management presented in a practical, yet creative style by our highly talented authors, who teach with us in The Difficult Airway Course: Emergency and The Difficult Airway Course: Anesthesia, The Difficult Airway Course: Critical Care and The Difficult Airway Course: EMS As with previous editions, each topic has undergone a critical appraisal of the available literature to ensure the content is on the vanguard of clinical medicine New information sparks vigorous debate and oftentimes a departure from previous thinking To this end, the fifth edition contains several fundamental changes The seven Ps of rapid sequence intubation (RSI), unadulterated fixtures in previous editions, have undergone a transformative change with the elimination of Pretreatment as a discrete pharmacologic action, now replaced by Preintubation Optimization With new information surfacing about the hemodynamic consequences of RSI in critically ill emergency department patients, this new step emphasizes the importance of maximizing cardiopulmonary physiology prior to induction and positive pressure ventilation in order to prevent hypoxic insult and circulatory collapse A new chapter on intubating the unstable patient dovetails nicely with this approach and provides a solid framework that addresses the metabolic, physiologic, and hemodynamic factors that make emergency airway management complex and challenging Cutting-edge information on flush flow rate oxygen for emergency preoxygenation provides us with new insight and options for maximizing the safety of RSI Lidocaine, previously advocated as a pretreatment agent for patients with elevated intracranial pressure and reactive airways disease, no longer plays a role and has been removed from our lexicon; however, fentanyl remains as a sympatholytic option in patients with hypertensive crises, although is now considered part of a holistic approach to cardiovascular optimization and is no longer thought of as an independent pharmacologic maneuver We present updated mnemonics for difficult airway detection with the “MOANS” mnemonic for difficult bag and mask ventilation refreshed to create “ROMAN,” which better highlights our newly understood association between radiation changes (the “R” in ROMAN) and difficult bagging In addition, we cover the latest in airway tools as old standbys like the GlideScope and C-MAC videolaryngoscopes continue to transform into more streamlined and affordable devices with improved image quality and overall performance This compendium embodies what we believe to be the knowledge and skill set required for emergency airway management in both the emergency department and the prehospital environment The principles, however, are applicable to a wide array of clinical settings As inpatient care continues to evolve and roles become redefined, we are witnessing the emergence of hospitalists and critical care physicians as primary airway managers being called upon frequently to intubate on hospital floors and in intensive care units The concepts we present in the fifth edition can be extrapolated to any arena where urgent airway management might take place and is as relevant to inpatient clinicians as it is to emergency medicine specialists Tapping yet again into Terry Steele’s vision and creativity, we drew upon the combined knowledge base from both the anesthesia and emergency medicine courses to develop The Difficult Airway Course: Critical Care in 2016, a comprehensive and robust new curriculum to meet the educational needs of this unique group of airway managers New chapters on intubating the unstable patient and safe extubation techniques augments this new curriculum and helps to make this latest edition the most versatile manual ever We are fortunate for the opportunity to provide this resource and are hopeful that the material in this book will play an important role when, late at night, faced with little information, less help, and virtually no time for debate we are called to act, make extraordinary decisions, and save lives Calvin A Brown III, MD Boston, Massachusetts John C Sakles, MD Tucson, Arizona Nathan W Mick, MD, FACEP Portland, Maine Acknowledgments One of the most precious gifts in medicine is that of mentorship and I have been fortunate beyond measure My development as an academic emergency physician would not have been possible without the frequent advice, incredible opportunities, and genuine friendship from Dr Ron Walls While professional aspirations are important, family is paramount I must thank my wife Katherine and our two wonderful boys, Calvin and Caleb Their steadfast love and support despite years of travel and long office hours has provided me with the privilege to pursue my professional goals Finally, I would like to acknowledge the national teaching faculty of our airway courses as well as the faculty, residents, and medical students at Brigham and Women’s Hospital and Harvard Medical School who help keep me energized, challenged, and intellectually honest on a daily basis Calvin A Brown III, MD Boston, Massachusetts There are many people in my life, including my family, professional colleagues, and patients, who have greatly enriched my career and have made my participation in the airway course and manual possible I thank them all for their understanding, continued support, and faith in me I would like to dedicate this manual to all the frontline providers, of every specialty and discipline, who manage the airways of critically ill and injured patients It is through their tireless efforts, working in uncontrolled environments and under difficult circumstances, that the lives of our loved ones are saved John C Sakles, MD Tucson, Arizona Ten years ago, I was contacted by Dr Ron Walls asking if I would be available to help teach at the Difficult Airway Course and it was with great honor and pleasure that I accepted his offer Today, I remain immensely grateful to him for his teaching and mentorship during residency and in the early portion of my academic career A decade has passed, and I feel blessed to have interacted with such an amazing group of airway educators and often feel as if I have received as much as I have given during those long weekends A special thanks to Dr Bob Luten, who has a special place in my heart as one of the founding fathers of Pediatric Emergency Medicine and a true pioneer in pediatric airway management Thank you as well to my family, wife Kellie, daughters Gracyn and Afton, for putting up with the frequent travel, with only the occasional “snow globe” present on my return Know that time away from the family is never easy, but we feel we are truly making a difference Nathan W Mick, MD, FACEP Portland, Maine Pressure support ventilation (PSV), 62, 68 Procedural sedation, 362 ventilation monitoring, 82 Progesterone, 415 Prolonged seizure activity airway approach to, 424 airway obstruction during, 424 anesthesia and, 424–426, 424b, 425b causes of, 426 challenges of, 423 grand mal, 424 ICP during, 426 intubation indications for, 423, 424b RSI and, 425, 425b status epilepticus as, 423, 424b tips for, 426–427 Propofol (Diprivan), 240, 375 adverse effects of, 255 in awake intubation sedation, 278 clinical pharmacology of, 255 contraindications for, 255 dosage of, 255, 440t indications for, 255 as induction agent, 240, 251, 254–255, 258, 431–432 ketamine used with, 279, 280 lidocaine used with, 255 for obese patients, 440t for patients with seizures, 424, 425, 425b, 426, 427 for pediatric airway, 290t reactive airways disease and, 403, 405 for RSI, 258 for trauma patients, 384, 388t ProSeal LMA (PLMA), 419 Prostigmin See Neostigmine Provence of Alberta, Canada, 359 Pseudocholinesterase (PCHE), 264, 267 PSV See Pressure support ventilation Psychomotor airway skills, 333 PTV See Percutaneous transtracheal ventilation Pulmonary aspiration, 454t Pulmonary edema (PE), 64 Pulmonary embolism, in ETCO2, 83 Pulmonary hyperinflation, 405 Pulse oximetry, 7, 32, 236, 424 during emergency airway management, 83 indication, 76 limitations and precautions, 76, 76t measurement principles, 75 physiologic insight and limitations, 77–78 response time, 77 signal reliability, 76–77 Pyridostigmine, 263 Q Quantitative CO2 monitors, 79, 79f Quetiapine, 242f R Ramped position, for obese patients, 340, 341f Rapid Fit connectors, 455f Rapid four-step cricothyrotomy technique (RFST), 211, 219–222 beginning position for, 219 disadvantages of, 230 intubation in, 221, 221f landmark identification in, 219, 220f no-drop technique compared with, 230 palpation in, 219, 219f skin incision in, 219, 220f traction applied in, 219–220, 221f Rapid Oral Tracheal Intubation Guidance System (ROTIGS) airway, 186, 186f Rapid sequence airway (RSA), 332, 361, 362 Rapid sequence intubation (RSI), 347, 371 adverse events in, 244 airway obstruction and, 410, 412 benzodiazepines, 258 blind intubation techniques and, 201 BMV and, 58 contraindications for, 235–236 cricothyrotomy and, 210 in difficult airways, 9–11, 15, 18, 19, 33–34 double setup for, 34 and drug use, 370b for emergency airway management, 49 etomidate, 257 example of, 244, 244t for geriatric patients, 430–431 hemodynamic consequences of, 246 ICP and, 396b, 397–399 indications for, 27–28f, 29–30, 201, 206, 235–236, 274 induction agents in, 257–258 ketamine, 257 ketofol, 258 paralysis, 432 for pediatric airway, 295–296, 317, 322 positioning in, 243t, 244t, 296, 396b, 418, 425b, 436, 438f, 439 postintubation management, 432 during pregnancy, 301 preintubation optimization for, 431–432 preparation for, 236, 243t, 244t, 295, 396b, 417, 425b prolonged seizure activity and, 425, 425b propofol, 258 reactive airways disease and, 402–403, 405, 406, 407 Rapid sequence intubation (RSI) sedation and, 240, 247, 361 Sellick’s maneuver during, 239, 246–247, 296 steps of, 3, 236b, 243t, 244t paralysis, 239, 243t, 244t, 296, 418, 425b placement with proof, 239–240, 243t, 244t, 296, 396b, 418, 425b positioning, 239, 243t, 244t, 296, 396b, 418, 425b, 439, 441 postintubation management, 240–243, 240t, 242f, 243t, 244t, 296, 396b, 403–405, 418–419, 425b, 426, 441 preintubation optimization, 243t, 244t, 296, 396b, 417 preoxygenation, 236–238, 237f, 243–244, 243t, 244t, 245, 296, 396b, 417, 425, 425b preparation, 236, 243t, 244t, 295, 396b, 417, 425b in trauma patients, 389 success of, 32, 210, 244 succinylcholine, 432, 433 timing of, 243–244 trauma patients, 386 Reactive airways disease See also Asthma; Chronic obstructive pulmonary disease anesthesia for, 401, 402f, 403, 405 barotrauma with, 404 catecholamines and, 403 challenges of, 401–402, 402f desaturation with, 402 in geriatric patients, 432 hemodynamic stability and, 401, 404 hypotension with, 405 mechanical ventilation for, 62, 68, 401–403, 402f postintubation management for, 403–405 RSI and, 405 technique for, 403 treatment of, 401, 402f, 403–407 Receptor upregulation, 266 Recruitment maneuvers (RMs), 442 Reflectance oximeters, 77 Reflex sympathetic response to laryngoscopy (RSRL), 394 Reintubation, airway exchange catheter (AEC) for, 456t, 457, 457t, 459 Remifentanil, 279 Rescue oxygenation, 58 Respiratory compromise, 370–371 Respiratory depression, 82 patients assessment and monitoring in, 83 Respiratory rate (RR), 67–69 Respiratory therapist (RT), 63, 73 Restricted neck movement, 318 Resuscitation, 55–56f, 372, 373 Retroglottic devices (RGDs), 99, 115–120 ETT See also Combitube complications, 119 insertion technique, 117–119 King LT airway, 115, 117f, 119–120 Rusch EasyTube, 115, 116f, 119, 121 Return of spontaneous circulation (ROSC), 81 Reversible conditions, intubation and, RGDs See Retroglottic devices Rhabdomyolysis, 266, 424, 424b Richmond Agitation Sedation Scale, 240, 241b Right ventricular failure, 376b Rigid bronchoscopy, 313 Rigid fiber-optic stylets, 191 Bonfils fiberscope as, 196–197, 197f, 199–200 video RIFL (RIgid Flexible Laryngoscope), 197–198, 198f Robinul See Glycopyrrolate Rocuronium, 243, 258, 264, 269–271, 270t, 395, 396b dosage of, 269, 433, 440t for geriatric patients, 432 for obese patients, 440t for pediatric airway, 290t, 296, 297 pregnancy and, 416, 418 for RSI in trauma patient, 388 sugammadex reversing, 271 RODS mnemonics, 17, 21, 29, 382, 417 ROMAN mnemonics, 16–17, 20–21, 29, 128, 340, 382, 416, 417 ROSC See Return of spontaneous circulation ROTIGS airway, 186, 186f RR See Respiratory rate RSI See Rapid sequence intubation RSRL See Reflex sympathetic response to laryngoscopy RT See Respiratory therapist Rusch EasyTube, 115, 116f, 119, 121 Rushed/frantic laryngoscopy, 151t S Safe apnea time, 49 Salicylate toxicity, 371 Salivary glands, 40 SCh See Succinylcholine Sedation See also Induction agents for awake intubation, 254, 274, 278–279 contraindications for, 274 description of, 274 during extubation, 458 indications for, 274 induction drugs, 374 ketamine, 324 procedural, ventilation monitoring, 82 Richmond Agitation Sedation Scale for, 240, 241b RSI and, 240, 247 techniques for, 274 Sedation-facilitated intubation (SFI), 361 Seizures See also Prolonged seizure activity grand mal, 424 self-limited, 424 Seldinger technique for cricothyrotome, 209, 222–223, 223f, 309b Melker Universal Cricothyrotomy Catheter Set for, 223f for pediatric airway, 309b steps of, 222 Self-inflating bags, 87, 152 Self-limited seizures, 424 Sellick maneuver, 94, 96, 239, 246–247, 296, 301, 417 Semielective exchange, for ETT blind exchange, 129 consideration of, 128 endoscopic exchange, 130–132, 131f, 132f performance of, 128–132 removal after intubation, 132 removal with routine intubation via direct/video laryngoscopy, 128 surgical airway, 132 techniques, 129t working around device and performing intubation with direct/video laryngoscopy, 129 Semirigid fiber-optic stylets, 191 Clarus Levitan scope as, 195–196, 196f, 199 Clarus Video System, 195, 195f SOS as, 191, 192–193 Semirigid intubating stylet, 35 Sensor location, pulse oximetry, 76t Sepsis, 371 decreased systemic vascular resistance in, 373 etomidate and, 257 ketamine and, 257 shock, 376b Septic shock, 257 Severe infections, 266 Severe metabolic academia (MA), 377b SGDs See Supraglottic devices Shock, 5, 257, 385–386 Shock index (SI), 372 Signal degradation, pulse oximetry, 76t Signal reliability, pulse oximetry, 76–77 SIMV See Synchronized intermittent mandatory ventilation “Single attempt” rescue device, 100 Single-handed mask hold, 92, 92f Smart cable, 162 SMART mnemonics, 18, 29, 128, 210, 210b, 382 Smoke inhalation, 383–384, 387t Sniffing position, 143, 144f, 153, 202, 288t, 303, 303f, 341f Sodium bicarbonate, 267 SOS See Clarus Shikani optical stylet Spine immobilization, 382 Spine injury See Cervical spine injury Standard direct laryngoscopy technique, 140f, 144, 145f, 147f Status asthmaticus, 4, 63 Status epilepticus, 423, 424b Steroids, 257 Stridor, 6–7, 6b, 15, 298, 411 Stylets, 148f See also Fiber-optic stylets; Rigid fiber-optic stylets; Semirigid fiberoptic stylets curved tube, 159 pediatric, 285t usage of, 206, 236 Subdiaphragmatic abdominal thrusts, 324 Subglottic stenosis, 222b Sublimaze See Fentanyl Succinylcholine (SCh), 28f, 32, 152, 237, 247, 263–264, 322, 396b, 398, 455t ACH molecules composing, 264 adverse effects of bradycardia, 264, 267 fasciculations, 265 hyperkalemia, 264, 271, 290 malignant hyperthermia, 267–268 prolonged neuromuscular blockade, 267 trismus/masseter muscle spasm, 268 atropine used with, 264 clinical pharmacology of, 264 contraindications for, 264, 418 degradation of, 267 denervation and, 271 dosage, 264–265, 270t, 433, 440, 440t for geriatric patients, 432 ICP influenced by, 395 indications, 264 myopathies and, 266, 271 NMBAs and, 268, 269, 270t for obese patients, 440, 440t for pediatric airway, 266, 290, 290t, 297 pregnancy and, 416 during prolonged seizure activity, 425, 425b, 426 reactive airways disease and, 403 for RSI in trauma patient, 388 Succinylmonocholine, 264 Sufentanil, 251 Sugammadex, 264, 269, 271 Superior laryngeal nerve, 44f, 277, 278f Supplemental oxygen high-concentration oxygen versus bag-valve mask, 55 high-flow oxygen with standard flowmeters, 53 nasal cannula, 52 nonrebreather mask, 52–53 simple face mask, 52 venturi mask, 55 Supraglottic devices (SGDs), 99, 100–104, 111–112, 112–113, 418 See also Laryngeal mask airway Supraglottic foreign body, identification of, 324 Supraglottitis See Epiglottitis Surgical airway management See also Cricothyrotomy; Percutaneous transtracheal ventilation anatomy and, 211, 213–214f complications of, 222b contraindications for, 209–210 decision making in, 210, 221 description of, 209 indications for, 209–210 injuries from, 221, 222b landmarks in, 211 during pregnancy, 417, 418 in prehospital setting, 230 technique comparison for, 230 tips for, 229 training for, 230 SVR See Systemic vascular resistance Swallowing, Sympathetic stimulation beta-blockers influencing, 394 fentanyl influencing, 398 ketamine influencing, 257 of larynx, 42 lidocaine influencing, 394, 398 opioids influencing, 394 RSRL as, 394 Synchronized intermittent mandatory ventilation (SIMV), 69 Systemic vascular resistance (SVR), 256 Systolic blood pressure (SBP), 372 T Tactile digital intubation See Digital tracheal intubation TBI See Traumatic brain injury Tenaculum, 445 Tension pneumothorax, 240 Terbutaline, 401 Tetracaine, 276 Thenar mask hold method, 93 in seated patients, 93f Thiopental, 251, 290t Thoracostomy, needle, 446 Thoracostomy tube, 238b 3-3-2 rule, 13, 14f, 19–21, 183, 382 Thyrohyoid membrane, 277 Thyrohyoid space, 211 Thyroid cartilage, 211, 213f, 216–217f during laryngoscopy, 153 Thyroid pressure See Backward, Upward, Rightward Pressure (BURP) maneuver Tidal volume (TV), 62, 67, 294, 404 Tissue edema, 372 Tongue during blind intubation, 205 during laryngoscopy, 40 in pediatric airway, 288t, 289f, 291, 302 Tonsils, 288, 288t suction, 188 Topical anesthesia spray, 90 Topicalization, 457, 458 Total body weight (TBW) dosing, 440 Towel clip, 445 Trachea anatomy of, 38f, 44, 44f, 287f anesthesia techniques for, 277–278 examination of, extrathoracic, 284, 287f hook, 212b, 215, 217f, 219, 220f injury to, from surgical airway, 221, 222b intrathoracic, 287f intubation confirmed in, 205 in pediatric airway, 284, 287f, 288, 288t, 306 Tracheal intubation, 184 confirmation, 152 in direct laryngoscopy, 141, 144, 148f, 149 endotracheal tube (ETT) in, 141, 148f GlideScope video laryngoscope (GVL), 162, 163f Tracheostomy awake, 280 tube for, 212b, 212f, 216, 218f, 221f, 229 Traditional direct laryngoscopy, 163 Traditional two-handed mask hold, 92f, 93, 95 Transmission oximetry, 75 Transport ventilator, 349 Transtracheal catheters, 224, 225–226f, 227, 306t Transtracheal jet ventilation See Percutaneous transtracheal ventilation Transtracheal needles, 224–226, 225–226f Trauma airway management airway injury, 387t brain injury, 387t cervical spine, 387t chest injury, 387t shock, 387t Trauma patients See also Difficult airway airway approach, 381–386 clinical challenges, 381 clinical considerations for brain injury, 384 cervical spine injury, 384–385 chest trauma, 385 hypotension, 394 injury to the airway, 383–384 shock, 385–386 failed airway, 388 LEMON airway mnemonics for, 382, 384 pediatric difficult airway in, 317 RODS airway mnemonics for, 382, 384 ROMAN airway mnemonics for, 382, 384 SMART airway mnemonics for, 382, 384 technique induction agent, 388 neuromuscular blocking agent, 388 paralysis versus rapid tranquilization, 386 preintubation optimization, 386 rapid sequence intubation, 386 Traumatic brain injury (TBI), 258, 383t, 384, 393, 396, 398 Trismus/masseter muscle spasm, 268 Trousseau dilator, 212b, 216, 220 Truphatek truview laryngoscopes components, 179–180, 180f versus Macintosh laryngoscope glottic view, 182 intubation time, 182 operation, 180 visualization, 181 Truview PCD laryngoscope, 179, 180f Tubarine See D-tubocurarine Turnout coat, 346f TV See Tidal volume Two-handed mask hold, 92f, 93–94, 95 U Ultrasound, in obese patient, 442 Uncompensated shock, 372, 375 Unexpected pediatric difficult airway therapeutic options, 312t Universal emergency airway algorithm, 26, 27f, 332 Unstable patients clinical challenge, 369 optimization for first laryngoscopy attempt success, 369–375, 370b hemodynamic optimization, 373–374 induction, 374 mechanical ventilation, 374–375 postintubation sedation, 375 preoxygenation considerations, 372–373 timing of airway management, 370–372 Upper airway See also Obstruction, of upper airway anatomy of, 37–43, 38f, 214f, 410 distortion of, 5, 409–413, 416 larynx of, 6, 15, 17, 21, 38f, 41–44, 42–43f, 204, 206, 213, 213–214f, 222, 222b, 224, 277, 288t, 308f, 412 mouth of, 13–15, 38f, 40–41, 40f, 42f, 273, 276 nose of, 37–39, 38f, 39f, 202–205, 276 obstruction, 6b, 452, 454t pharynx in, 38f, 41, 42f, 204 tongue of, 40, 206, 288, 288t, 289f, 302 trachea of, 6, 38f, 43f, 44, 205, 221, 222b, 277–278, 284, 287f, 288, 288t, 306 V Vagus nerve, 44f, 277 Valium See Diazepam Vallecula, 178 Vascular engorgement, 416 Vasoconstriction anesthesia with, 276 epinephrine causing, 284 nasal, 188, 202, 276 Vasodilated shock, 371 Vasopressors, 371, 372, 373 VC ventilation See Volume cycled ventilation Vecuronium, 242f, 243, 268–269, 270t dosage of, 440t for obese patients, 440t for pediatric airway, 290t pregnancy and, 416 during prolonged seizure activity, 425b Ventilation assist control (AC), 69 bag-mask ventilation (BMV) See Bag-mask ventilation (BMV) continuous positive airway pressure (CPAP), 69 control mode ventilation (CMV), 68–69 in emergency medical services (EMS) airway, 332 failure of, 4–5 foreign body aspiration and, 445–446, 445f maintenance of, 31, 33–34 mechanically ventilated patients, 83 See also Mechanical ventilation monitoring during procedural sedation, 82 synchronized intermittent mandatory ventilation (SIMV), 69 Ventilation–perfusion (V/Q) mismatches, 436, 437b Ventilator-induced lung injury (VILI), 72 Ventilators, 363 pressure-limited, 295t, 404 VILI from, 72 volume-limited, 295t, 404 Ventolin See Albuterol Ventrain ventilation device, 224 Venturi mask, 51t, 55 Verathon, 159 Versed See Midazolam Video laryngoscopy (VL), 3, 11, 13, 16, 21, 25, 29, 29f, 30f, 35, 175, 195, 236, 273, 343, 344f, 385, 411, 412, 453, 458, 459 advantages of, 158 C-MAC video laryngoscope, 164–166 classification of, 158, 158t complications of, 160 difficult pediatric airway, 317 versus direct laryngoscopy, 362 GlideScope video laryngoscope (GVL), 160–164 King Vision video laryngoscope (KVL), 168–170 McGrath video laryngoscope series 5, 166–168 overview of, 157 Pentax Airway Scope (AWS), 170–172 routine intubation, 128 success rates in pediatrics, 362 technique for, 159–160 tube advancement, 159–160 tube delivery, 159 visualization, 159 working around EGD, 129, 130f Video recording system, in C-MAC video laryngoscope, 164 Video RIFL (RIgid Flexible Laryngoscope), 197–198, 198f Visualization Cormack–Lehane grading system for, 12, 12f, 196 of epiglottis, 178, 288, 411 foreign body, 325 of glottis, 12, 13, 34, 42, 141, 145–146, 148–149, 150f, 153, 166, 175, 191, 195, 196, 203, 274, 304, 382, 385, 389, 390, 457 of larynx, 206, 288t, 412 Vocal cords, 12f, 17, 19, 139, 142f, 144, 153, 178, 180, 205, 287f, 454t Volume cycled ventilation (VCV), 69–70, 70f, 295t, 404 flow characteristics, 69–70 waveform, 70f Volume-limited ventilators, 295t, 404 V/Q mismatches See Ventilation–perfusion (V/Q) mismatches W Waveform capnography, 79f, 126, 127f, 363 CO2 monitoring, 79 Wheezing, in children, 323 Wi-Fi camera, 178, 179f Williams airway, 186f Wire guide technique, 222, 230 WOB See Work of breathing Work of breathing (WOB), 62, 69 X X X-blade, 168 Xenon, 252 Xylocaine See Lidocaine ... patient for emergency airway management, the first assessment should be of the patency and adequacy of the airway In many cases, the adequacy of the airway is confirmed by having the patient...FIFTH EDITION THE WALLS MANUAL OF EMERGENCY AIRWAY MANAGEMENT EDITOR-IN-CHIEF Calvin A Brown III, MD Assistant Professor of Emergency Medicine Director of Faculty Affairs Department of Emergency. .. protects his airway, and ventilation and oxygenation are adequate, intubation is indicated as part of the management of the constellation of injuries (i.e., as part of the overall management of the patient)