A 5-year-old boy is brought to the emergency department by his grandmother because of difficulty breathing. Over the past two hours, the grandmother has noticed his voice getting progressively hoarser and occasionally muffled, with persistent drooling. He has not had a cough. The child recently immigrated from Africa, and the grandmother is unsure if his immunizations are up-to-date. He appears uncomfortable and is sitting up and leaning forward with his chin hyperextended. His temperature is 39.5°C (103.1°F), pulse is 110/min, and blood pressure is 90/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Pulmonary examination shows inspiratory stridor and scattered rhonchi throughout both lung fields, along with poor air movement. Which of the following is the most appropriate next step in management?

Prepare for emergency airway management in the operating room with anesthesia and ENT backup

Direct laryngoscopy and pharyngoscopy

Immediate nasotracheal intubation in the emergency department

Intravenous administration of antibiotics

A 36-year-old male with fluctuating levels of consciousness is brought to the emergency department by ambulance due to a fire in his home. He currently opens his eyes to voice, localizes painful stimuli, responds when asked questions, but is disoriented and cannot obey commands. The patient’s temperature is 99°F (37.2°C), blood pressure is 86/52 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. Physical exam shows evidence of soot around the patient’s nose and mouth, but no burns, airway obstruction, nor accessory muscle use. A blood lactate is 14 mmol/L. The patient is started on intravenous fluids. What is the next best step in management?

100% oxygen, hydroxycobalamin, and sodium thiosulfate

Sodium thiosulfate and sodium nitrite

A 5-year-old is brought into the emergency department for trouble breathing. He was at a family picnic playing when his symptoms began. The patient is currently struggling to breathe and has red, warm extremities. The patient has an unknown medical history and his only medications include herbs that his parents give him. His temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 70/40 mmHg, respirations are 18/min, and oxygen saturation is 82% on 100% O2. Which of the following is the best initial step in management?

Albuterol, ipratropium, and magnesium

A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

Intubation and mechanical ventilation

Insertion of nasogastric tube and enteral nutrition

Intravenous corticosteroid therapy

A 24-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was a restrained driver. On arrival, he is alert and oriented. His pulse is 112/min, respirations are 29/min, and blood pressure is 100/60 mm Hg. The pupils are equal and reactive to light. There is a 3-cm laceration over the forehead and multiple bruises over the trunk. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. The right knee is swollen and tender; range of motion is limited by pain. Infusion of 0.9% saline is begun and intravenous acetaminophen is administered. Two hours later, blood-tinged fluid spontaneously drains from both nostrils, and is made worse by leaning forward. On a piece of gauze, it shows up as a rapidly-expanding clear ring of fluid surrounding blood. Further evaluation of this patient is most likely to show which of the following?

Bilateral periorbital ecchymosis

Airway management techniques for USMLE Step 2 CK: High-Yield Surgery Lessons

🗺️ The Airway Roadmap

Pre-procedure Assessment: Crucial for anticipating a difficult airway.
- 📌 LEMON Mnemonic for difficult intubation:
  - Look externally: trauma, large incisors, beard.
  - Evaluate 3-3-2 Rule: <3 fingers mouth opening, <3 fingers hyoid-mental distance, <2 fingers thyroid-to-floor of mouth.
  - Mallampati Score: Class ≥III predicts poor glottic view.
  - Obstruction/Obesity: Stridor, muffled voice, high BMI.
  - Neck Mobility: Limited C-spine movement (e.g., rheumatoid arthritis).

Mallampati Classification Scores I-IV for Airway Assessment

Stepwise Intervention Ladder:
- Basic: Head-tilt/chin-lift, jaw thrust.
- Adjuncts: OPA (no gag reflex), NPA (intact gag reflex).
- Advanced: LMA (supraglottic), ETT (definitive).
- Failed Airway: Surgical cricothyrotomy.

⭐ Cormack-Lehane grade, assessed during laryngoscopy, predicts intubation difficulty. Grade III (epiglottis only) or IV (no glottic structures) signals a need for alternative strategies like video laryngoscopy or fiberoptic intubation.

🛠️ Management - Tools of the Trade

Basic Airway Adjuncts:
- Oropharyngeal Airway (OPA): For unconscious patients (no gag reflex). Measured from corner of mouth to angle of mandible.
- Nasopharyngeal Airway (NPA): For conscious/semiconscious patients. ⚠️ Contraindicated in basilar skull fracture (risk of intracranial placement).
Supraglottic Airways (SGA):
- Laryngeal Mask Airway (LMA): Sits over the laryngeal inlet. Used for anesthesia in short procedures. Does not protect against aspiration.
Definitive Airways (Endotracheal Intubation):
- Laryngoscopy:
  - Macintosh (curved): Tip placed in the vallecula.
  - Miller (straight): Directly lifts the epiglottis.
- Endotracheal Tube (ETT): Cuffed tube past vocal cords. Gold standard for airway protection.

⭐ The most reliable method to confirm ETT placement is persistent capnography (end-tidal CO₂ detection). Auscultation and chest rise are initial checks but less definitive.

Laryngoscope insertion and epiglottis lifting technique

💃 Management - The Intubation Dance

Rapid Sequence Intubation (RSI) is the standard for emergent airway management to minimize aspiration risk.

Induction Agents:
- Etomidate: Hemodynamically neutral; risk of adrenal suppression.
- Ketamine: Bronchodilator (good for asthma); increases ICP/IOP.
- Propofol: Potent vasodilator; causes hypotension.
Paralytic Agents:
- Succinylcholine: Depolarizing; fast onset/offset. ⚠️ Risk of severe hyperkalemia (burns, crush injury, denervation).
- Rocuronium: Non-depolarizing; slower onset, longer duration.

⭐ Cricoid pressure (Sellick maneuver) was historically used during RSI but is no longer routinely recommended due to lack of proven efficacy and potential to worsen the laryngoscopic view.

🆘 Complications - The Rescue Mission

Laryngospasm: Involuntary vocal cord adduction.
- Management: 100% O₂ with positive pressure, deepen anesthesia, succinylcholine if severe.
Bronchospasm: Wheezing, ↑ peak airway pressures.
- Management: Deepen anesthesia, β2-agonists, epinephrine.
Aspiration:
- Management: Trendelenburg, suction oropharynx, bronchoscopy if particulate matter.

⭐ Laryngospasm can often be "broken" with gentle, continuous positive airway pressure (CPAP) around 15-20 cm H₂O (the "Larsen's Maneuver" jaw thrust can also be applied).

⚠️ CICO (Can't Intubate, Can't Oxygenate) Algorithm:

⚡ Biggest Takeaways

The Laryngeal Mask Airway (LMA) is a supraglottic device that does not protect against aspiration.

The Endotracheal Tube (ETT) is the definitive airway, providing aspiration protection and positive pressure ventilation.

Predict a difficult airway using the Mallampati score (Class III/IV) and LEMON criteria.

Rapid Sequence Intubation (RSI) is critical for patients with a full stomach to prevent aspiration.

Persistent end-tidal CO2 (capnography) is the most reliable method to confirm ETT placement.

A cricothyrotomy is the emergent surgical airway for a "can't intubate, can't oxygenate" scenario.

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