Generate appropriate airway assessment and management practice scenarios for EMT/EMS based on the provided chapter excerpts.

EMT/EMS Airway Assessment and Management Practice Scenarios

Scenario 1: Unconscious Patient with Snoring Respirations

Clinical Presentation:

• 58-year-old male found unresponsive in parking lot
• Snoring respirations audible from 10 feet away
• RR: 8 breaths/min, SpO₂: 86% on room air
• No obvious trauma, strong radial pulse

Assessment Focus:

• Recognize snoring = tongue obstruction requiring immediate manual airway maneuver 1
• Assess level of consciousness using AVPU scale 2
• Perform cross-finger technique to visually inspect airway for foreign bodies or secretions 1
• Check for gag reflex to determine OPA vs NPA appropriateness 3

Management Algorithm:

1. Open airway with head-tilt chin-lift (no trauma suspected), maintaining ear-to-sternal notch alignment 1
2. Insert OPA if no gag reflex present - this improves but does not replace manual maneuver 4
3. Apply nonrebreather at 15 L/min targeting SpO₂ >94% 4
4. Monitor with continuous waveform capnography if available to confirm adequate ventilation 4, 3
5. Prepare BVM - if RR remains <8 or SpO₂ doesn't improve, begin assisted ventilation at 1 breath every 6 seconds 1

Critical Pitfall: Do not assume adequate oxygenation means adequate ventilation - hypercarbic drive failure can occur with SpO₂ still appearing acceptable initially 1

---

Scenario 2: Pediatric Foreign Body Airway Obstruction

Clinical Presentation:

• 3-year-old child at restaurant, suddenly unable to speak
• Universal choking sign (hands at throat)
• Parent states child was eating grapes
• Child conscious but unable to cough effectively
• Cyanosis developing around lips

Assessment Focus:

• Distinguish complete vs incomplete obstruction - inability to speak/cough = complete 1
• Assess for air movement using look-listen-feel approach 1
• Monitor for progression to unconsciousness (indicates complete obstruction with hypoxia) 1

Management Algorithm for Complete Obstruction:

1. 5 back blows between shoulder blades with child leaning forward 1
2. THEN abdominal thrusts (Heimlich) - 5 cycles 1
3. Repeat sequence until object expelled or child becomes unconscious 1
4. If unconscious: Begin CPR immediately, visualize airway before each ventilation attempt to remove visible object 1
5. Do NOT perform blind finger sweeps - risk pushing object deeper 1

Critical Pitfall: For incomplete obstruction (can cough/speak), encourage continued coughing and observe - "less is more" approach prevents converting partial to complete obstruction 1

---

Scenario 3: COPD Patient with Respiratory Distress

Clinical Presentation:

• 72-year-old with known COPD, increasing dyspnea over 3 days
• RR: 32 breaths/min with accessory muscle use
• SpO₂: 88% on home oxygen at 2 L/min via nasal cannula
• Pursed-lip breathing, speaking only 2-3 words per breath
• Diminished lung sounds bilaterally with expiratory wheezes

Assessment Focus:

• Recognize hypoxic drive dependency in COPD patients - avoid excessive oxygen 1
• Assess work of breathing: intercostal retractions, nasal flaring, tripod positioning 1
• Determine adequacy of ventilation: tidal volume (chest rise) and rate 1
• Listen for lung sounds - diminished = low volume, unilateral = pneumothorax 1

Management Algorithm:

1. Position upright to optimize respiratory mechanics 1
2. Titrate oxygen carefully: Start with nonrebreather at 15 L/min targeting SpO₂ 90-94% (NOT 100%) 1
3. Consider CPAP if nonrebreather insufficient - patient must be awake, able to follow commands, maintain own airway, and NOT hypotensive 1, 3
4. CPAP contraindications: Hypotension, inability to protect airway, facial trauma preventing mask seal 1
5. If inadequate ventilation develops (RR <8 or >40, declining mental status): Transition to BVM with two-person technique 1, 3

Critical Pitfall: CPAP is the bridge between nonrebreather and BVM - use it proactively before respiratory failure occurs, especially in pulmonary edema 1

---

Scenario 4: Trauma Patient with Suspected Cervical Spine Injury

Clinical Presentation:

• 24-year-old ejected from vehicle, found 20 feet from car
• GCS: 10 (E3, V3, M4), combative
• Obvious facial trauma with blood in oropharynx
• C-collar applied by first responders
• RR: 24, SpO₂: 91% on nonrebreather
• Gurgling sounds with each breath

Assessment Focus:

• Gurgling = fluid in upper airway requiring immediate suctioning 1
• Assess airway patency while maintaining spinal precautions 1
• Recognize altered mental status (GCS <15) = cannot protect airway 1, 2
• Anticipate difficult airway: Facial trauma, blood, secretions, limited neck mobility 1

Management Algorithm:

1. Immediate suctioning - turn patient on side (logroll with spinal precautions) if copious secretions 1
2. Jaw thrust maneuver (NOT head-tilt chin-lift) to open airway while maintaining spinal alignment 1
3. Insert NPA if patient semi-conscious with gag reflex - CONTRAINDICATED if basilar skull fracture suspected (Battle's sign, raccoon eyes, CSF rhinorrhea) 1
4. Prepare for rapid sequence intubation - this patient needs definitive airway due to GCS <8 trajectory and inability to protect airway 1
5. Have surgical airway equipment ready - facial trauma increases failed intubation risk 1

Critical Pitfall: NPA in basilar skull fracture can penetrate brain - if head injury suspected with clear fluid from nose/ears, use OPA only or prepare for immediate advanced airway 1

---

Scenario 5: Cardiac Arrest with Difficult Ventilation

Clinical Presentation:

• 68-year-old male in cardiac arrest, CPR in progress
• Morbidly obese (estimated 350 lbs), short neck
• Single rescuer attempting BVM with poor chest rise
• SpO₂: unreadable, no waveform capnography available yet
• Dentures in place

Assessment Focus:

• Recognize inadequate ventilation: Absent/inadequate chest rise, gastric distention developing 1, 4
• Identify anatomical difficult airway features: obesity, short neck, limited mouth opening 1
• Two-person BVM is standard - single rescuer technique is compromise 1, 3

Management Algorithm:

1. STOP single-rescuer BVM immediately - call for second rescuer 1
2. Leave dentures in place unless loose - they actually facilitate mask seal 1
3. Two-person BVM technique: One person creates two-handed EC-clamp seal, second person squeezes bag 1, 3
4. Optimize positioning: Place padding under shoulders to achieve ear-to-sternal notch alignment in obese patient 1
5. Insert OPA to maintain airway patency (no gag reflex in cardiac arrest) 4
6. Ventilate 1 breath every 6 seconds (10 breaths/min) during CPR, avoid hyperventilation 1, 3
7. Confirm ventilation with waveform capnography once available - mandatory for all advanced airways 4, 3

Critical Pitfall: Excessive ventilation during CPR decreases coronary perfusion pressure and survival - strict adherence to 10 breaths/min 3

---

Scenario 6: Pediatric Status Asthmaticus

Clinical Presentation:

• 7-year-old with known asthma, severe respiratory distress
• RR: 48 breaths/min, SpO₂: 89% on nonrebreather
• Severe intercostal and suprasternal retractions
• Nasal flaring, belly breathing pattern
• Minimal air movement on auscultation (silent chest)
• Altered mental status (lethargic, not recognizing parents)

Assessment Focus:

• Silent chest = impending respiratory arrest - minimal wheezing worse than loud wheezing 1
• Pediatric-specific signs: nasal flaring, belly breathing, tracheal tugging 1
• Altered mental status = hypoxia/hypercarbia requiring immediate intervention 1
• Bradycardia in pediatric hypoxia = pre-arrest (unlike adults who develop tachycardia) 1

Management Algorithm:

1. Position of comfort (usually upright) - do not force supine 1
2. High-flow oxygen via nonrebreather at 15 L/min - hypoxia overrides concerns about oxygen toxicity 1
3. Prepare for assisted ventilation - this child is in respiratory failure 1, 3
4. Pediatric BVM technique: Smaller mask, less volume, faster rate (1 breath every 3 seconds = 20 breaths/min) 1
5. Avoid excessive pressure - pediatric airways more compliant, easier to cause barotrauma 1
6. If family present: Consider having parent hold blow-by oxygen near face if child fighting mask 1

Critical Pitfall: Pediatric patients compensate longer then decompensate rapidly - altered mental status in respiratory distress = imminent arrest requiring aggressive intervention 1, 2

---

Scenario 7: Anaphylaxis with Stridor

Clinical Presentation:

• 32-year-old with known peanut allergy, ate at new restaurant
• Complains of throat tightness, difficulty swallowing
• High-pitched inspiratory stridor audible
• Urticarial rash on chest and arms
• RR: 28, SpO₂: 93% on room air
• Speaking in short sentences, anxious

Assessment Focus:

• Stridor = upper airway obstruction from swelling - life-threatening 1
• Assess progression: Can patient speak? Swallow? Maintain own airway? 1
• Recognize anaphylaxis triad: Cutaneous findings + respiratory + cardiovascular involvement 1
• Monitor for rapid deterioration - airway edema can progress within minutes 1

Management Algorithm:

1. Epinephrine 0.3-0.5 mg IM immediately (not in EMT scope but critical to recognize need) 1
2. High-flow oxygen via nonrebreather at 15 L/min 1
3. Position upright to reduce airway edema and optimize breathing 1
4. Prepare advanced airway equipment - if stridor worsening, intubation needed BEFORE complete obstruction 1
5. Do NOT delay transport - this patient needs hospital-based airway management 1, 3
6. Have surgical airway equipment ready - angioedema creates anatomically difficult airway 1

Critical Pitfall: Stridor that suddenly stops may indicate complete obstruction, not improvement - immediate surgical airway may be needed 1

---

Scenario 8: Altered Mental Status with Inadequate Ventilation

Clinical Presentation:

• 45-year-old found unresponsive at home by family
• Empty pill bottles nearby (suspected overdose)
• RR: 6 breaths/min, shallow chest rise
• SpO₂: 82% on nonrebreather at 15 L/min
• Pinpoint pupils, no response to verbal stimuli
• Strong carotid pulse, BP: 110/70

Assessment Focus:

• RR <8 = inadequate ventilation requiring assisted ventilation regardless of SpO₂ 1
• Recognize opioid toxidrome: Pinpoint pupils, respiratory depression, altered consciousness 1
• Distinguish oxygenation from ventilation - SpO₂ may be acceptable but CO₂ retention occurring 1
• Assess for gag reflex to determine airway adjunct 3

Management Algorithm:

1. Begin BVM immediately - inadequate ventilation (RR <8) is absolute indication 1, 3
2. Two-person technique: One maintains EC-clamp seal, one ventilates 1
3. Insert OPA if no gag reflex (likely absent given profound CNS depression) 4
4. Ventilate at 1 breath every 6 seconds with just enough volume for chest rise 1
5. Monitor with waveform capnography if available - target ETCO₂ 35-45 mmHg 4, 3
6. Reassess frequently - if patient begins fighting BVM, transition to NPA and nonrebreather 1

Critical Pitfall: Nonrebreather alone is insufficient for inadequate ventilation - must provide positive pressure ventilation with BVM when RR <8 or >40 1

---

Scenario 9: Tracheostomy Emergency

Clinical Presentation:

• 62-year-old with permanent tracheostomy at home
• Family called 911 for "difficulty breathing"
• Tracheostomy tube appears partially dislodged
• Audible whistling sound around stoma site
• RR: 36, SpO₂: 85%, using accessory muscles
• Patient alert but panicked

Assessment Focus:

• Recognize tracheostomy displacement - whistling = air leak around tube 1
• Assess whether tube is patent or obstructed - suction to clear secretions 1
• Determine if ventilation possible through tracheostomy vs need for upper airway 1
• Waveform capnography critical for monitoring tracheostomy complications 1

Management Algorithm:

1. Attempt to ventilate through tracheostomy using BVM directly over stoma (remove mask, use just bag adapter) 1
2. If ventilation unsuccessful: Remove tracheostomy tube completely 1
3. Cover stoma with gloved hand and attempt ventilation via mouth using BVM with mask 1
4. If still unsuccessful: Ventilate through stoma directly with BVM (no tube) while occluding mouth/nose 1
5. Suction frequently - tracheostomy patients have increased secretions 1
6. Apply oxygen via tracheostomy collar if patient ventilating adequately after intervention 1

Critical Pitfall: Do not assume tracheostomy patients cannot be ventilated via mouth - if tracheostomy fails, cover stoma and use standard upper airway techniques 1

---

Scenario 10: Multi-System Trauma with Cannot Ventilate/Cannot Intubate

Clinical Presentation:

• 28-year-old motorcycle crash, GCS: 6
• Massive facial trauma, blood obscuring anatomy
• Multiple failed intubation attempts by paramedics
• Cannot achieve adequate BVM ventilation despite two-person technique
• SpO₂: 78% and falling, bradycardia developing
• Mottled skin, cyanosis

Assessment Focus:

• Recognize "cannot ventilate/cannot intubate" crisis - immediate surgical airway needed 1
• Identify signs of profound hypoxia: Bradycardia, mottling, cyanosis 1
• Limit intubation attempts to 3 - persistent attempts cause trauma, edema, bleeding 1
• Assess for surgical airway landmarks: cricothyroid membrane 1

Management Algorithm:

1. STOP further intubation attempts - recognize failed airway 1
2. Optimize BVM: Two-person technique, suction blood, reposition head, insert OPA 1, 4
3. If BVM still inadequate: Prepare for surgical cricothyroidotomy 1
4. Identify cricothyroid membrane: Between thyroid and cricoid cartilages 1
5. EMT role: Recognize need, assist paramedic/physician, prepare equipment, continue oxygenation attempts 3
6. Post-procedure: Confirm placement with waveform capnography, secure airway 4, 3

Critical Pitfall: Persistent failed intubation attempts delay definitive surgical airway - recognize failure early and transition to front-of-neck access 1