Ensure that the hypopharynx is adequately visualized. This process has been done traditionally byassessing the Mallampati classification. In supine patients, the clinician can estimate Mallampati score by asking the patient to open the mouth fully and protrude the tongue; a laryngoscopy light is then shone into the hypopharynx from above to assess the extent of hypopharynx that is visible.O = Obstruction:Any condition that can cause obstruction of the airway will make laryngoscopy and ventilation difficult.N = Neck Mobility: This is a vital requirement for successful intubation. In a patient with non-traumatic injuries, clinicians can assess mobility easily by asking the patient to place his or her chin on the chest and then extend the neck so that he or she is looking toward the ceiling. Patients who require cervical spinal motion restriction obviously have no neck movement and are therefore more difficult to intubate.Continued
n BACK TO TABLE OF CONTENTSAIRWAY MANAGEMENT 29box 2-1 lemon assessment for difficult intubation (continued)Mallampati Classifications.These classifications are used to visualize the hypopharynx. Class I:soft palate, uvula, fauces, pillars entirely visible; Class II:soft palate, uvula, fauces partially visible; Class III:soft palate, base of uvula visible; Class IV:hard palate only visible.n FIGURE 2-4Airway Decision Scheme.Clinicians use this algorithm to determine the appropriate route of airway management. Note: The ATLS Airway Decision Scheme is a general approach to airway management in trauma. Many centers have developed other detailed airway management algorithms. Be sure to review and learn the standard used by teams in your trauma system.
30 CHAPTER 2 nAirway and Ventilatory ManagementnBACK TO TABLE OF CONTENTSalgorithm applies only to patients who are in acute respiratory distress or have apnea, are in need of an immediate airway, and potentially have a c-spine injury based on the mechanism of injury or physical examination findings. (Also see functional Airway Decision Scheme on MyATLS mobile app.)The first priority of airway management is to ensure continued oxygenation while restricting cervical spinal motion. Clinicians accomplish this task initially by positioning (i.e., chin-lift or jaw-thrust maneuver) and by using preliminary airway techniques (i.e., nasopharyngeal airway). A team member then passes an endotracheal tube while a second person manually restricts cervical spinal motion. If an endotracheal tube cannot be inserted and the patient’s respiratory status is in jeopardy, clinicians may attempt ventilation via a laryngeal mask airway or other extraglottic airway device as a bridge to a definitive airway. If this measure fails, they should perform a cricothyroidotomy. These methods are described in detail in the following sections.