Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step

We report a case of prehospital “cannot intubate” and “cannot ventilate” scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20？min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2？min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm. 1. Introduction We report a case of difficult airway management performed in the prehospital environment. Initial attempts at airway management revealed a “cannot intubate” scenario followed by a “cannot ventilate” scenario. Although primary and secondary backup devices failed, tertiary rescue devices succeeded for each arm of the algorithm. Our case reinforces the imperative for strictly following a difficult airway management algorithm (DAMA) that includes several airway devices; that the algorithm should be rapidly navigated is necessary as well as activation of successive preplanned steps of the algorithm. 2. Case Report The medical emergency medical team of the prehospital unit of a general hospital was sent to the house of a 57-year-old morbidly obese patient (BMI 40？kg m-2) because of status epilepticus. Upon arrival on the scene, the patient was found lying on the floor. Initial vital signs were as follows: pulse 115 ？min-1, respiration 21 ？min-1, blood pressure (S/D) 175/105？mmHg, and arterial oxygen saturation 83%. The Glasgow Coma Scale was 7 (E = 2 V = 2 M = 3). Chest auscultation revealed that gastric content aspiration had probably occurred. Tracheal intubation was urgently indicated. After a short period of bag-mask oxygenation, blow by oxygen (12？L min-1), arterial oxygenation with spontaneous ventilation reached 93%–94%. Sellick maneuver was applied prior to performing a rapid sequence induction using thiopental (300？mg) and