Emergency Airway Management and Scene Assessment for EMS

Scene safety

Comes before patient contact.

Primary assessment

Treat airway, breathing, major bleeding, and perfusion threats as they are found.

Agonal gasps

Not adequate breathing.

Ventilation

Only until visible chest rise; avoid excessive rate or volume.

Critical patients

Need early transport decisions and frequent reassessment.

Documentation

Must be objective, chronological, complete, and corrected without hiding the original entry.

Airway management

Begins with recognizing whether air can move from the environment to the alveoli.

Airway anatomy

Air travels through the nose or mouth, pharynx, larynx, trachea, main bronchi, smaller bronchi, bronchioles, and alveoli.

Upper airway

Generally includes the nose, mouth, pharynx, and larynx.

Lower airway

Begins below the vocal cords.

Infant airway characteristics

Proportionally larger tongues and occiputs, smaller and more easily obstructed airways.

Inhalation

Active process at rest; diaphragm and intercostal muscles contract.

Exhalation

Usually passive at rest; forced exhalation is active.

Clinical death

Period after breathing and circulation stop but before irreversible cellular injury.

Brain death

Irreversible loss of all functions of the entire brain, including the brainstem.

Agonal respirations

Irregular, gasping breaths that may occur during cardiac arrest.

Apnea

Complete absence of spontaneous breathing.

Gastric distention

Air entering the stomach during positive-pressure ventilation.

Recovery position

A side-lying position for a patient who is breathing adequately.

Stomas

Surgically created opening in the neck connecting the trachea to the outside.

Foreign-body airway obstruction (FBAO)

Partial obstruction may allow coughing or speech; severe obstruction causes poor or absent air movement.

Sellick maneuver / cricoid pressure

Backward pressure over the cricoid cartilage; routine use is generally not recommended.

CO2 detectors

Devices that detect exhaled carbon dioxide to confirm and monitor placement of an advanced airway.

Abnormal airway sounds

Often identify where an obstruction or respiratory problem is occurring.

Head-tilt, chin-lift

Preferred manual airway maneuver when trauma is not suspected.

Jaw-thrust maneuver

Used when spinal injury is suspected; limits neck movement.

Breath sounds

Listen bilaterally over upper and lower lung fields; assess presence, equality, intensity, and abnormal sounds.

Snoring respirations

Low-pitched sound caused by the tongue or relaxed soft tissues partially blocking the upper airway.

Gurgling respirations

Wet sound caused by blood, vomit, mucus, or other fluid in the upper airway.

Wheezes

High-pitched musical sounds caused by narrowed lower airways.

Crackles / rales

Discontinuous popping sounds associated with fluid or the opening of collapsed small airways.

Diminished or absent breath sounds

May result from shallow breathing, poor air movement, or other conditions.

Paradoxical chest movement

A chest segment moves inward during inhalation and outward during exhalation.

Oropharyngeal airway (OPA) - indication

Use for an unresponsive patient without a gag reflex.

OPA - contraindications

Do not use in a conscious or semiconscious patient with an intact gag reflex.

OPA - measuring

Select a size that reaches from the corner of the mouth to the angle of the jaw.

OPA - insertion

Open the mouth, clear visible obstruction, and insert without pushing the tongue backward.

Nasopharyngeal airway (NPA) - indication

Use for a patient who needs an airway adjunct but has an intact gag reflex, clenched jaw, or oral injury, provided no contraindication is present.

NPA - contraindications and cautions

Avoid with suspected basilar skull fracture or severe midface trauma, and follow local protocol for anticoagulation or nasal obstruction. Do not force the device if resistance is encountered.

NPA - measuring

Measure from the tip of the nose to the earlobe or angle of the jaw. The diameter should approximate the patient's smallest finger or nostril.

NPA - insertion

Lubricate with water-soluble lubricant, bevel toward the septum, and advance gently along the floor of the nostril - usually the right nostril for a standard bevel. If resistance occurs, stop and try the other nostril when appropriate; never force it.

Suctioning

Suction removes fluids and secretions that obstruct ventilation or create aspiration risk.

Suction equipment

A functioning portable or mounted suction unit, rigid tonsil-tip catheter for the mouth and pharynx, flexible catheter for the nose, stoma, or advanced airway, tubing, collection container, PPE, and oxygen or ventilation equipment.

Rigid catheter technique

Measure only as far as you can see or to the corner of the mouth. Insert without suction, suction while withdrawing, and sweep the visible oral cavity. Avoid blindly advancing beyond view.

Flexible catheter technique

Use for areas a rigid catheter cannot access. Preoxygenate when possible, insert without suction to the appropriate depth, and apply suction while withdrawing. Follow device and protocol limits.

Maximum suction times

Common EMT teaching limits one attempt to about 15 seconds in an adult, 10 seconds in a child, and 5 seconds in an infant, with oxygenation or ventilation between attempts. Local protocols and patient response take priority.

When secretions cannot be cleared quickly

If large amounts of vomit or secretions prevent ventilation, turn the patient or use log-roll precautions when indicated, clear the mouth rapidly, suction, and resume oxygenation or ventilation. Airway and oxygenation are the priorities.

Oxygenation and Ventilation Devices

Oxygenation adds oxygen to the blood; ventilation moves air into and out of the lungs and removes carbon dioxide. A patient may need one or both.

Nasal cannula

Provides low-to-moderate supplemental oxygen and is often better tolerated by a breathing patient. A common flow range is 1-6 L/min, with delivered concentration affected by the patient's breathing.

Nonrebreather mask

Provides high-concentration oxygen to a spontaneously breathing patient. Inflate the reservoir first and use enough flow - commonly 10-15 L/min - to keep the bag from collapsing during inhalation.

Venturi mask

Delivers a more precise oxygen concentration through interchangeable adapters. It is used more often in facilities but may be available in some EMS systems.

Nebulizer mask

Uses oxygen or air flow to aerosolize medication for inhalation. It is a medication-delivery device rather than a substitute for assisted ventilation.

CPAP

Continuous positive airway pressure provides pressure throughout spontaneous breathing, helping keep alveoli open and reduce work of breathing.

CPAP contraindications and cautions

Do not use in apnea, inadequate spontaneous breathing, inability to protect the airway, active vomiting, severe altered mental status, or inability to tolerate the mask.

Mouth-to-mouth ventilation

Advantage: immediately available and can provide effective breaths. Disadvantages: direct exposure, no reliable high-concentration oxygen unless specialized equipment is used, fatigue, and difficulty maintaining a seal.

Mouth-to-mask ventilation

Advantages: barrier protection, generally easier seal than a BVM for one rescuer, and many masks permit supplemental oxygen.

Bag-valve-mask (BVM) ventilation

Advantages: provides positive-pressure ventilation, can deliver high oxygen concentrations with a reservoir, and limits direct contact.

Effective BVM technique

Position the airway, insert an adjunct when indicated, use a two-handed mask seal when possible, and squeeze slowly over about one second only until visible chest rise.

Flow-restricted oxygen-powered ventilation device (FROPVD)

A manually triggered, oxygen-powered device that delivers positive-pressure breaths.

Scene Size-Up

The scene size-up begins before patient contact and protects the crew, patient, and bystanders while identifying resources and likely injuries or illness.

B - BSI / standard precautions

Select PPE based on anticipated exposure, such as gloves, eye protection, mask or respirator, and gown.

S - scene safety

Look for traffic, fire, electricity, hazardous materials, violence, weapons, animals, unstable structures, environmental threats, and escape routes.

N - number of patients

Determine how many patients are present and whether triage or a multiple-casualty response is needed.

A - additional resources

Request resources early, such as fire, rescue, law enforcement, hazardous-materials teams, advanced life support, air medical transport, utilities, or additional ambulances.

M - mechanism of injury or nature of illness

MOI describes the forces that may have caused trauma; NOI describes the medical complaint or disease process.

E - evaluate for spinal motion restriction

Assess the mechanism, symptoms, neurologic findings, reliability, and local selective spinal-motion-restriction criteria.

General impression

An immediate overall view of age, position, distress, skin signs, breathing effort, interaction, surroundings, and apparent severity.

AVPU

Alert; responsive to Verbal stimuli; responsive to Pain; Unresponsive.

Chief complaint

The patient's main symptom or reason EMS was called, preferably recorded in the patient's own words.

Airway assessment

Determine whether the airway is open and maintainable; look and listen for obstruction, secretions, swelling, trauma, abnormal sounds, or inability to speak.

Breathing assessment

Assess rate, depth, rhythm, effort, chest rise, breath sounds, oxygenation, skin signs, and ability to speak.

Circulation assessment

Assess pulse rate and quality, major bleeding, skin color, temperature and moisture, and signs of perfusion.

Transport decision

Determine urgency, destination, need for rapid packaging, and whether advanced resources are needed.

Exam decision

Choose a focused assessment for a stable patient with a specific complaint or a rapid head-to-toe exam for significant trauma.

Differential diagnosis

A prioritized list of possible causes for the patient's findings.

Secondary Assessment

Gathers a more complete history and examination after immediate life threats have been addressed.

Focused exam

A targeted assessment of the body system or injured area related to a specific complaint in a stable patient.

Rapid exam

A rapid head-to-toe assessment used for significant mechanisms, altered or unresponsive patients.

SAMPLE history

Signs and symptoms; Allergies; Medications; Pertinent past history; Last oral intake; Events leading to the illness or injury.

OPQRST

Onset; Provocation or palliation; Quality; Region or radiation; Severity; Time.

Baseline vital signs

Initial measurements used for comparison, commonly including mental status, pulse, respirations, blood pressure, skin signs, pupils, oxygen saturation, and pain.

Detailed assessment

A more comprehensive head-to-toe or systems examination performed when time, condition, and protocol allow.

DCAP-BTLS

Deformities, Contusions, Abrasions, Punctures or penetrations, Burns, Tenderness, Lacerations, and Swelling.

Golden period

A teaching concept emphasizing that severely injured patients benefit from rapid recognition, essential stabilization, and timely definitive care.

Platinum 10 minutes

A goal of limiting scene time to roughly 10 minutes for selected critical trauma patients.

Reassessment

Determines whether the patient is improving, worsening, or responding to treatment.

Reassessment sequence

Repeat the primary assessment, reconsider the chief complaint, reassess interventions, repeat vital signs.

Reassessment frequency

A common guideline is every 5 minutes for an unstable or critical patient and every 15 minutes for a stable patient.

Trending

Compare sequential findings rather than relying on one measurement.

Communication

Clear communication supports dispatch, medical control, hospital preparation, teamwork, and continuity of care.

FCC

The Federal Communications Commission regulates interstate and international communications by radio, television, wire, satellite, and cable.

Radio report

A concise prearrival report that includes unit identification, estimated arrival, patient age and sex, chief complaint or mechanism.

Hand-off report

A face-to-face transfer of essential information and responsibility to the receiving clinician.

Communication principles

Be brief, organized, accurate, objective, and professional.

Patient Care Report (PCR)

A chronological, objective record of dispatch information, scene findings, history, assessments, vital-sign trends, treatments.

Abbreviations

Use only agency-approved, unambiguous abbreviations.

PCR as a legal document

A PCR may be used in court, audits, investigations, billing, and quality improvement.

Pertinent negatives

Relevant findings that were specifically assessed and absent.

Patient refusals

Document decision-making capacity, assessment findings, recommended care, risks and alternatives explained.

Correcting errors

Never erase, obscure, delete, backdate, or falsify information.