Disclaimer: This website is for study and revision purposes only. It is not medical advice and should not be relied upon in real-world patient care. By using this website, you acknowledge and agree to our Medical Disclaimer.
Airway with C-Spine
The purpose of the airway assessment is to ensure that the airway is clear, open, and maintained. If the casualty cannot maintain their own airway, for example due to being unconscious, then airway management will be required. A blocked or unmaintained airway will quickly lead to hypoxia, hypoxic brain injury, and potential cardiac arrest.
However, this assessment and any subsequent management should be done with C-spine considerations in mind. Manual stabilisation of the C-spine will be required if the mechanism of injury suggests a possible spinal injury.
Assess the Airway
The first step is to ensure that the airway is clear and remains clear ongoing. Even if the casualty is talking does not mean that the airway is clear and will not be obstructed. You should consider the risk of items within the mouth obstructing the airway. This could be teeth, debris, blood, vomit.
Additionally listen to the breathing for snoring, gurgling, stridor, or wheezing. Other indicators of an airway issue can include difficulty breathing such as use of accessory muscles, cyanosis, or reduced consciousness.
Clear the Airway
Obstructions such as blood, vomit, and foreign bodies must be removed. Therefore, you must check inside the mouth to look for obstructions and potential obstructions. However, consider the risk of the client reacting and biting the responder. Therefore, wherever possible options such as suction and Magill forceps should be used. If this is not possible then a finger sweep may be used but should be avoided if possible.
If there is no concern regarding spinal injuries, then postural drainage can be used to clear the airway.
Open the Airway
Once any potential obstructions have been removed, if the casualty cannot open and maintain their own airway you should open the airway using an airway manoeuvre.
If the c-spine has not been cleared then a jaw-thrust should be used, otherwise a head tilt-chin lift may be used.
Maintaining the Airway
If the casualty cannot maintain their own airway, then an airway adjunct can be used. However, this will be limited based on both the scope of practice of the responder and the available equipment. For example, at the FREC3 level responders are only generally trained in the use of OPA and NPA; whereas at FREC4 the use of i-Gel becomes an option.
There are also several advanced airway management options such as tracheal intubation and surgical cricothyrotomy, but these are generally restricted to Paramedics and Critical Care Paramedics (CCPs).
Airway Adjuncts
An Oropharyngeal Airway (OPA/Guedel) may be used on an unconscious casualty with an absent gage reflex. They are sized from the corner of the mouth to the angle of the jaw. In adults they are inserted inverted (“Invert, Insert, Rorate”) but in children it is a straight insertion. They cannot be used if the gag reflex is present or with oral trauma (or in some cases of facial trauma).
A Nasopharyngeal Airway (NPA) may be used in an unconscious or semi-conscious casualty. They can be used where an OPA is not tolerated or is contraindicated – however they can also be used alongside an OPA. They are sized from the tip of the nose to the tragus (the small triangle of cartilage at the front of the ear canal). The average female will require a 6mm and the average male will require a 7mm. They should be lubricated prior to insertion and inserted by following the floor of the nose. However, they should not be used in cases of suspected basal skill fracture, facial trauma, or cerebrospinal fluid leak.
Where the scope of practice allows, an i-Gel may be used. These are supraglottic airway devices which can be used to secure and maintain an open airway when manual manoeuvres and basic adjuncts are insufficient. These are sized based on the casualty’s weight and are colour coded. An adult weighing 50-90Kg will require a size 4 (green) and a large adult weighing 90+ Kg will require a size 5 (Orange). They should be lubricated on the back, sides, and tip of the device. They will typically be connected to a bag-valve-mask (BVM) for assisted ventilation.
Reassess
The airway should be continually monitored for obstruction – and suction, forceps, or positioning utilised as required.
Once the airway is clear, open, and maintained, move on to assess respiration.