Difficult and Failed Airway Drills

In this video Eyston Vaughan-Huxley (KSS HEMS Doctor) and Ben Clarke (KSS HEMS Paramedic) demonstrate protocolised strategies to manage difficult or failed airway scenarios in the pre-hospital setting.

This video pertains to a non-trauma patient and not all aspects of clinical care are portrayed. The emergency front-of-neck technique is adapted to the setting and differs slightly to the DAS technique presented in Week 2

Why Are Airway Drills Important?

Previous steps have discussed some of the challenges of the pre-hospital setting including environmental issues and human factors. However, it is important not to neglect the technical challenges that add to the risks associated with pre-hospital airway management. It is imperative to have a pre-determined plan for a failed airway scenarios.

Technical Airway Challenges

It is not uncommon to encounter patients with pathology of the head and neck. There may be anatomical disruption of the airway, swelling from injuries such as burns, or significant airway haemorrhage. All of these scenarios can make the technical skills of facemask ventilation, supraglottic airway insertion, laryngoscopy, intubation and front of neck access difficult and, in some cases, impossible.

There may be clues in the history and examination as to the potential for a difficult airway but there is seldom any information to indicate previous airway or anaesthetic complications. In addition, patients are located remotely, where there is limited equipment and almost no option for backup, yet a difficult airway may still need to be managed.

It is precisely for situations like these that preparation is imperative and having well drilled protocols are essential to improve the likelihood of success.

Management Strategies

Regular training is the key to making the difficult airway as easy to manage as possible.

Protocols (see Figure 1) should be introduced during initial training scenarios and reinforced through regular practice during governance days and clinical shifts. Regular rehearsal generates muscle memory and reduces cognitive loading in a crisis. You may remember the top tip offered by Dr Fiona Kelly in the activity on Human Factors: “Good technical skills help improve non-technical skills”

Having a standardised approach to the RSI kit dump and airway drills creates a shared mental model between crew members and builds team confidence to progress through the management options and ultimately secure the airway.

Operators should develop and maintain a wide range of basic and advanced airway skills to optimise first attempt success, including: facemask ventilation, supraglottic airway insertion, competence with a range of direct and video laryngoscopes and experience with front of neck airway techniques.

Training in a range of challenging scenarios develops situational awareness and the communication strategies required in a crisis; this in turn optimises the CRM between the team managing the patient’s airway and the wider team on scene.

Figure 1: Protocolised difficult & failed airway management drills Credit: KSS Standard Operating Procedures