There are many “unknowns” at this stage, so several scenarios may be running through your head in anticipation of the patient’s arrival. What is their level of consciousness? Is the patient already intubated, or will they even need intubation in the immediate term before any evaluation or imaging is done in the emergency department? What was the mechanism of injury and how much energy transfer was involved in the accident? How likely is a neck injury? Have attempts already been made to intubate by pre-hospital personnel? Could there be blood in the airway? Is the patient hemodynamically stable or getting worse as time passes? All of these are good considerations to focus your attention and prepare for what might need to be done. More will be revealed when the patient arrives and additional history is gathered.

Perhaps the first order of business is to identify whether or not intubation is needed at this time. Assessment of vital signs (and their trend), mental status (and its trend), mechanism of injury, need for surgery (immediate or delayed), and any plans for imaging in the ED before deciding on surgery will all impact the decision about when or whether to intubate. With all these seemingly simultaneous decisions to make, it is worth bearing in mind the patient’s multiple risks for nonoptimal status (due to trauma, cervical collar, full stomach, etc.) and to plan accordingly.

Urgency for securing the airway would include respiratory distress, worsening mental status, hemodynamic instability portending shock, or aspiration.

This patient presents in an awake state, which is a major advantage as it allows a more thorough airway evaluation in terms of history and physical examination. Indeed, the ASA Guidelines recommend that, whenever feasible, before the initiation of anesthetic care and airway management, an airway history and physical examination should be conducted [1].

The airway physical examination should similarly be conducted whenever feasible. The purpose is to detect physical characteristics that may indicate the presence of a difficult airway. It is also recommended that multiple airway features should be assessed.

The patient’s history with a focus on the airway can be revealing and should be ascertained. The past surgical history for this patient includes sinus surgery. If practical and feasible, more information about this should be sought, such as if there were any difficulties with the intubation for that procedure, or how recently it was performed (concern for friable tissue or inflammation should a nasal approach to intubation or use of a nasal trumpet be considered as she presents now), and the original indication for the surgery (e.g., polyps, tumor removal, epistaxis).

Another diagnosis this patient carries is asthma, and in characterizing this condition it would be useful to know if she has ever been intubated for this condition (not only could it provide information about the intubation, but would also likely be indicative of severe baseline airway disease). Other pertinent history is the frequency of inhaler use and whether oral steroids have been required to control symptoms.

One important history question is whether or not the patient snores. Compared to other history questions, this one is somewhat different in that the patient typically cannot rely on themselves for an accurate answer (though there are some patients who will admit to being woken up by the sound of their own snoring). Even when a patient does admit to snoring or being told that they snore, this information only occasionally will be recorded in the medical record, thus it may be “under the radar” of most practitioners. The practitioner for whom it probably matters the most is the anesthesiologist, as snoring is a risk factor for difficult mask ventilation.

In conducting a thorough airway history, it is important to keep in mind that even patients with no past surgical history can have revealing information about intubation if they have had nonsurgical conditions that require intubation (e.g., asthma, COPD exacerbation, sepsis, etc.)

This patient is awake and can participate in an airway exam at least to some degree. With the presence of the cervical collar, any exam will naturally be more limited. A basic evaluation under other circumstances would naturally include the range of motion of the neck, but this would clearly be ill-advised in a case such as this one. Cervical collars also restrict mouth opening (another basic part of the airway exam under normal circumstances).

The ASA Guidelines recommend that multiple airway features be assessed. It lists 11 features in all, though it also states this is not an exhaustive list, nor is it mandatory to evaluate all of them (again, the caveat of using judgment with respect to the clinical context about whether to evaluate certain aspects of the airway).

Of all the components of the airway physical exam only four, in fact, actually require patient cooperation:

The other seven components of the airway exam do not require patient cooperation and can be assessed externally by visual observation or with the gentle use of a tongue depressor. These assessments can provide significant and often critical information about the likelihood of encountering difficulty with intubation. These features include the following:

One physical feature that is not on this list but may be of clinical significance during intubation is that of the tongue size relative to the size of the oral cavity. This feature is somewhat related to the compliance of the submandibular space, in that this is the compartment into which the tongue would normally be displaced during direct laryngoscopy. Toward this point, the combination of a large tongue size and decreased submandibular compliance would compound the difficulty encountered compared to that for either feature alone.

Additionally, this patient has an elevated BMI, which raises concerns for both difficult mask ventilation (DMV) and difficult intubation (DI).

Overall, obtaining additional history is important and may lead to a change in approach to managing the airway. If the patient’s history reveals something concerning or serious, prior records should be obtained if they will be available in a timely manner and if it is practical to do so. In some cases, additional consultation (e.g., from an otorhinolaryngologist) may be in order to safely manage a difficult airway.

Obtaining prior records may be as fast and simple as looking up an anesthesia record in your own hospital’s electronic medical record system, or may be as prohibitively cumbersome as filing a request at another institution.

The decision of whether or not to delay intubation for the sake of obtaining prior records depends on how important the information might be in managing the patient’s airway at that moment in time, and keeping in mind the amount of time that may actually be available to obtain that information. In urgent/emergent situations such as in this case, the patient’s clinical status will guide the necessity of trying to garner additional history or obtain prior records.

The timing of when trauma imaging should take place is typically the purview of the emergency medicine physician or trauma team. While additional imaging may be useful to know, even “normal” results of a cervical CT scan cannot rule out some injuries (e.g., spinal cord contusion, ligamentous instability), thus the change in management from an airway management perspective would likely be minimal. It would be prudent to assume the c-spine is unstable at this stage of the clinical course.

After the patient’s history has been taken and airway physical examination has been completed, enough information should be available to assess the likelihood and clinical impact of the six basic airway management problems (as stated in the ASA Difficult Airway Algorithm) relative to the current clinical scenario. These problems are as follows:

It is noteworthy to observe from this list that ability to ventilate comes before ability to intubate. While so much focus is placed on the anesthesiologist’s ability to intubate, mask ventilation is the real lifesaving skill set when caring for a patient who is known or suspected to be a difficult intubation. In the case presented here, the luxury of evaluating the patient’s airway in the same manner as for an elective case is not available. This places more emphasis on correctly evaluating this patient’s risk factors for difficult mask ventilation.

The ASA Difficult Airway Algorithm delineates four basic choices with respect to managing the airway:

A similar decision-tree approach to airway management is the Airway Approach Algorithm (AAA) [2]. This algorithm has been described as a method to be used before applying the ASA Difficult Airway Algorithm.

Using the AAA, if it has been determined that the airway does need to be controlled, there are only two possible answer choices left: (1) awake intubation or (2) intubation after induction. These two choices correspond to the entry points in the ASA Difficult Airway Algorithm (the top of each box in the diagram).

Based on the pre-intubation assessment (physical exam, history), the likelihood of encountering difficulty with intubation or mask ventilation must be assessed.

Indications for an awake intubation include the following: