DCAS Airway Management & Intubation 3 — Questions and Answers
Question 1: Cricothyrotomy is indicated in which situation?
- Can't intubate, can't oxygenate (CICO) — failed airway with life-threatening hypoxia (Correct answer)
- Any failed first intubation attempt
- Patients with cervical spine injury
- Patients with known laryngeal cancer
Correct answer: Can't intubate, can't oxygenate (CICO) — failed airway with life-threatening hypoxia
Cricothyrotomy (surgical or needle) is a rescue intervention reserved for the CICO scenario — when all other airway methods have failed and the patient is dying of hypoxia — providing direct tracheal access below the obstruction.
Question 2: The cricothyroid membrane is located:
- Between the thyroid cartilage superiorly and the cricoid cartilage inferiorly (Correct answer)
- Below the cricoid cartilage
- Between the cricoid and the tracheal rings
- Above the thyroid cartilage
Correct answer: Between the thyroid cartilage superiorly and the cricoid cartilage inferiorly
The cricothyroid membrane is palpable between the thyroid cartilage (Adam's apple) superiorly and the cricoid cartilage (ring) inferiorly — the landmark for emergency surgical airway access.
Question 3: Post-intubation sedation and analgesia in the pre-hospital setting is important because:
- Paralysis from RSI wears off and an awake, intubated patient will fight the tube and hyperventilate (Correct answer)
- Sedation improves haemodynamics in all patients
- All intubated patients require neuromuscular blockade indefinitely
- Sedation reduces the need for monitoring
Correct answer: Paralysis from RSI wears off and an awake, intubated patient will fight the tube and hyperventilate
Neuromuscular blockade from succinylcholine wears off in 8-10 minutes; ongoing sedation and analgesia prevent patient awareness, fighting against the tube, self-extubation, and dangerous sympathetic responses.
Question 4: An end-tidal CO2 reading of 20 mmHg in a breathing, non-arrested patient after intubation suggests:
- Oesophageal intubation (or extreme hyperventilation) — verify tube position immediately (Correct answer)
- Correct tracheal intubation with mild hyperventilation
- Cardiac arrest with poor CPR quality
- Normal ventilation in a paediatric patient
Correct answer: Oesophageal intubation (or extreme hyperventilation) — verify tube position immediately
A very low ETCO2 of 20 mmHg in a breathing patient most likely indicates oesophageal intubation (where CO2 from a few gastric CO2 washes out rapidly) and must be immediately evaluated with laryngoscopy.
Question 5: The nasopharyngeal airway (NPA) is preferred over the oropharyngeal airway (OPA) in which situation?
- Semi-conscious patients with intact gag reflex, or patients with jaw clenching (trismus) (Correct answer)
- Deeply unconscious patients with no gag reflex
- Patients with facial trauma and suspected basilar skull fracture
- All paediatric patients under age 12
Correct answer: Semi-conscious patients with intact gag reflex, or patients with jaw clenching (trismus)
The NPA is better tolerated in patients with some level of consciousness and an intact gag reflex; it does not trigger the gag response as readily as an OPA and can be used when mouth opening is restricted.
Question 6: Bougie-assisted intubation is used when:
- Partial (limited) glottic view makes direct tube passage difficult — the bougie confirms tracheal entry via tactile feedback (Correct answer)
- The patient has a known easy airway
- VL provides a perfect glottic view
- Paediatric patients require smaller tube sizes
Correct answer: Partial (limited) glottic view makes direct tube passage difficult — the bougie confirms tracheal entry via tactile feedback
The bougie (endotracheal tube introducer) is passed through a limited glottic view; tracheal rings provide a 'clicks' tactile sensation, and the bougie stops as it wedges in the bronchus — both confirming tracheal placement before railroading the ETT.
DCAS Airway Management & Intubation 3
Cricothyrotomy is indicated in which situation?