2.2 Core Workflows and Decision Points

2.2 Core Workflows and Decision Points

Once basic measures are in place, the paramedic decides whether to place a supraglottic airway (SGA) or perform endotracheal intubation (ETI). Both are within paramedic scope; the choice depends on patient factors, predicted difficulty, transport time, and protocol.

Supraglottic airways

SGAs such as the i-gel, King LT, and laryngeal mask airway (LMA) are inserted blindly into the hypopharynx and seal over or around the glottic opening, requiring no laryngoscopy. They are fast, have high insertion success, and are the recommended initial advanced airway in many cardiac-arrest protocols because they minimize compression interruptions.

Limitations: they do not definitively protect against aspiration as well as a cuffed ET tube, high airway pressures can break the seal, and they may not seat well with significant facial/airway trauma. Confirm an SGA the same way you confirm an ET tube: bilateral breath sounds, chest rise, no epigastric sounds, and a sustained capnography waveform.

Direct versus video laryngoscopy

Direct laryngoscopy (DL) uses a Macintosh (curved, into the vallecula) or Miller (straight, lifts the epiglottis) blade and requires a direct line of sight to the cords. Video laryngoscopy (VL) places a camera at the blade tip, improving the glottic view and first-pass success, particularly in predicted difficult airways, soiled airways with adequate suction, and patients in manual in-line stabilization where neck movement is limited. The exam favors VL when difficulty is predicted or cervical-spine motion must be minimized.

The intubation sequence and tube confirmation

A disciplined sequence prevents hypoxic complications:

1. Preoxygenate for 3 minutes (or 8 vital-capacity breaths) targeting SpO2 of 100%; apply a nasal cannula at 15 L/min for apneic oxygenation.
2. Position in the sniffing position (ear-to-sternal-notch); use manual in-line stabilization for trauma.
3. Laryngoscopy for no more than ~30 seconds per attempt; if SpO2 falls below ~90%, abort and re-oxygenate with a BVM.
4. Pass the tube through the cords; adults seat at roughly 21-23 cm at the teeth.
5. Inflate the cuff and immediately confirm.

Multi-point confirmation

No single sign is sufficient; layer them.

A flat capnography tracing after intubation means esophageal placement until proven otherwise (in a perfusing patient) — pull the tube. In cardiac arrest, very low CO2 can also reflect minimal pulmonary blood flow, so correlate with breath sounds and the laryngoscopic view. If breath sounds are present on the right only with a high airway pressure, suspect right mainstem intubation and withdraw the tube 1-2 cm. Always re-confirm placement after every move (lifting onto the stretcher, into the ambulance) because dislodgement is a leading cause of preventable airway death.

Bag-valve-mask technique remains foundational

No matter how advanced your plan, BVM ventilation is the rescue you always fall back on, and poor technique is a common reason airways fail. Use the two-person, two-handed technique when possible: one provider uses both hands for a tight mask seal with a thenar-eminence or E-C grip while the second squeezes the bag. Ventilate just enough to produce visible chest rise — about 500-600 mL for an adult — at roughly 10-12 breaths per minute (one breath every 5-6 seconds).

The two most dangerous BVM errors are hyperventilation and excessive volume/pressure, which raise intrathoracic pressure, reduce venous return and cardiac output, and force air into the stomach, causing gastric distension, regurgitation, and aspiration. Gentle cricoid pressure and an adjunct (OPA/NPA) improve the seal and reduce insufflation.

Choosing the device: SGA versus ETI

Place an SGA first when speed matters and compressions cannot be interrupted (cardiac arrest), when intubation has failed, or when a predicted difficult airway makes laryngoscopy risky. Choose endotracheal intubation when you need the most definitive aspiration protection, when high ventilation pressures are expected (severe bronchospasm, pulmonary edema) that would break an SGA seal, for prolonged transport or interfacility transfer, and when RSI is indicated for a patient who needs paralysis to be intubated.

Either way, the bougie (a flexible introducer) is a high-yield adjunct: when only the epiglottis or a partial cord view is obtained, the bougie is passed first (feeling for tracheal-ring clicks) and the tube is railroaded over it, markedly improving first-pass success in difficult views.

First-pass success and apneic oxygenation

The quality metric for prehospital airways is first-pass success without hypoxia. Each additional laryngoscopy attempt multiplies the risk of desaturation, aspiration, and hemodynamic collapse. The behaviors that drive first-pass success are deliberate preoxygenation, optimal positioning, the right device chosen the first time, a bougie kept ready, and a nasal cannula left running at 15 L/min for apneic oxygenation throughout the attempt. If the SpO2 falls below roughly 90% mid-attempt, stop and re-oxygenate with the BVM before trying again.