Quick reference algorithm

Difficult Airway Algorithm

Trauma and emergency airway management · March 2026 edition

Double setup: surgical airway prepared simultaneouslyAttempt 3 is the last attempt before CICO

Trauma Airway Management • Adapted for Emergency/Trauma Setting

v1.0 • March 2026 • For institutional use only

Airway Assessment

LEMON assessment

Predictors:

short neck
limited mouth opening
facial trauma
C-spine injury
blood/secretions

DOUBLE SETUP — Prepare for Surgical Airway Simultaneously

Surgical cricothyrotomy kit open and ready
Call for help early
Designate team roles

RSI — Rapid Sequence Intubation

Pre-oxygenation
Apneic oxygenation (15 L/min NC)

RSI Medications

Ketamine1.5–2 mg/kg IV
Succinylcholine1.5 mg/kg IV
or
Rocuronium1.2 mg/kg IV

Avoid etomidate if adrenal concerns

Attempt 1

Video Laryngoscopy

VL as primary device (preferred)
Optimal positioning, external manipulation
Bougie available

Successful intubation ↓

Attempt 2

Adjust & Retry

Change blade size/type
Reposition (ear-to-sternal notch)
Bougie-assisted intubation
Different operator

Successful intubation ↓

Attempt 3 — MAX

Supraglottic Airway (SGA)

Insert LMA/i-gel as rescue
Oxygenate & ventilate through SGA
Consider intubation through SGA

This is the last attempt before CICO

Successful intubation ↓

If intubation successful

From any attempt. Separate from the CICO pathway above.

Successful Intubation

Confirm with ETCO₂ waveform
Secure tube
CXR confirmation
Post-intubation sedation/analgesia
Ventilator settings

If SpO₂ falling • unable to ventilate via SGA

Declare CICO

Can’t Intubate, Can’t Oxygenate

SpO₂ falling • Unable to ventilate via SGA

Immediate surgical airway

Surgical Cricothyrotomy

Scalpel-bougie-tube technique
Vertical skin incision → horizontal membrane
6.0 cuffed ETT or tracheostomy tube
Confirm with ETCO₂ waveform

Difficult Airway Algorithm

Assessment and preparation

Airway Assessment

DOUBLE SETUP — Prepare for Surgical Airway Simultaneously

RSI — Rapid Sequence Intubation

RSI Medications

Intubation attempts

Video Laryngoscopy

Adjust & Retry

Supraglottic Airway (SGA)

Outcomes

Successful Intubation

Declare CICO

Surgical Cricothyrotomy

Difficult Airway Algorithm

Assessment and preparation

Airway Assessment

DOUBLE SETUP — Prepare for Surgical Airway Simultaneously

RSI — Rapid Sequence Intubation

RSI Medications

Intubation attempts

Video Laryngoscopy

Adjust & Retry

Supraglottic Airway (SGA)

Outcomes

Successful Intubation

Declare CICO

Surgical Cricothyrotomy