Module 1
Basic Review of Endotracheal Intubation
for Providers at a Mass Casualty
Introduction
Airway management is at the core of care for the injured patient during a mass casualty event. In addition, emergency
surgery needs for multiple patients may necessitate the use of much conscious sedation to allow surgical care of a large number
of casualties. This will necessitate personnel other than anesthesia providers assisting with airway management. The
following review is intended to provide a basic overview of orotracheal intubation to support mass casualty airway care.
This review is tailored for perioperative care of such patients. The same principles would apply to any perioperative airway
care to include standard conscious sedation as we commonly employ for routine outpatient surgeries.
This review of basic intubation technique was prepared to support disaster medical training for the Chemical Care Casualty
Branch at Aberdeen Proving Grounds, MD. The same instructional format may be useful to support civilian conscious sedation
training. This narrative description is accompanied by slides which may be downloaded and used to support airway training
aspects of conscious sedation training at your facility.
IMPORTANCE OF AIRWAY MANAGEMENT
The vital importance of airway management is well documented in the anesthesia literature.
● While studying the incidence and causes of cardiac arrest due to
anesthesia, Keenan and Boyan reported that failure to provide adequate ventilation was responsible for 12 of 27 cardiac arrests
during the operative period.1,2
● The American Society of Anesthesiologists (ASA) closed-claims
study showed that the single largest source of unfavorable outcome during anesthesia was adverse respiratory episodes accounting
for 34% of 1541 liability claims.2,3
● Seventy-five percent of the undesirable events in this closed claims
study were due to: inadequate ventilation (38%), esophageal intubation (18%), and difficult tracheal intubation (17%).2,3
● Death and brain damage were outcomes in nearly 85% of the cases
studied.2,3
● Cheney et al, analyzed 300 liability claims for
ventilation-related undesirable outcomes and identified airway trauma, pneumothorax, airway obstruction, aspiration, and
bronchospasm as recurring patterns of management error or patterns of injury.2,4
Given these data, it is clear that management of the airway is key for safe perioperative care and for the care of the patient
with a compromised respiratory status during a mass casualty event.
BASIC AIRWAY MANAGEMENT
The following basic steps are important when managing the airway of a patient:
(1) A thorough airway history and physical examination must be performed.
(When this is not possible, e.g. with mass casualties, point 4 becomes even more important.)
(2) Develop a management plan for use of a supraglottic means of ventilation
(e.g. ventilation without intubation using devices such as a face mask, Combitube, Laryngeal Mask Airway [LMA], etc).
(3) A management plan for both intubation and extubation is necessary (the
difficult to intubate patient may need to remain intubated in some instances)
(4) An alternative plan of action should be formulated in case emergencies
develop or the patient is difficult to intubate / ventilate.2
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