A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 34-year-old man presents to the emergency department by ambulance after being involved in a fight. On arrival, there is obvious trauma to his face and neck, and his mouth is full of blood. Seconds after suctioning the blood, his mouth rapidly fills up with blood again. As a result, he is unable to speak to you. An attempt at direct laryngoscopy fails as a result of his injuries. His vital signs are pulse 102/min, blood pressure 110/75 mmHg, and O2 saturation 97%. Which of the following is indicated at this time?
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A
Endotracheal intubationIncorrect. Endotracheal intubation has already failed--direct laryngoscopy could not be performed due to facial trauma and ongoing hemorrhage. Repeated attempts waste time.
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B
CricothyroidotomyCorrect. Failed intubation with an unmaintainable airway requires immediate cricothyroidotomy--a surgical airway placed through the cricothyroid membrane, faster and simpler than tracheostomy in emergencies.
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C
Nasogastric tubeIncorrect. Nasogastric tube placement has no role in securing a definitive airway; it would not address the airway compromise.
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D
Cardiopulmonary resusicationIncorrect. CPR is indicated for cardiac arrest. This patient has a pulse (102/min) and is breathing--he needs an airway, not chest compressions.
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E
Awake fiberoptic intubationIncorrect. Awake fiberoptic intubation requires a cooperative patient and unobstructed visualization through the upper airway--neither is possible here with massive ongoing oral hemorrhage and failed direct laryngoscopy.
↑ Tap an answer to reveal the reasoning
Answer: B. This patient has severe maxillofacial trauma with ongoing oropharyngeal hemorrhage. He cannot maintain a patent airway, his mouth refills with blood despite suctioning, and direct laryngoscopy is impossible due to anatomic distortion and blood. This is a definitive failed-airway scenario that requires immediate surgical airway access.
Cricothyroidotomy is the emergency surgical airway of choice: a vertical skin incision over the cricothyroid membrane, a transverse incision through the membrane, and placement of a tracheostomy tube or endotracheal tube directly into the trachea. It bypasses the obstructed/unvisualizable upper airway and can be performed in <1 minute by trained providers.
Endotracheal intubation has already failed (direct laryngoscopy unsuccessful). A nasogastric tube has no role in airway management. CPR is for cardiac arrest; this patient has a pulse and is breathing. The decision rule: failed intubation + cannot oxygenate -> surgical airway (cricothyroidotomy). Cricothyroidotomy is preferred over tracheostomy in the emergency setting because it is faster and technically simpler.
**Why each option:**
**A.** Endotracheal intubation has already failed--direct laryngoscopy could not be performed due to facial trauma and ongoing hemorrhage. Repeated attempts waste time.
**B.** Correct. Failed intubation with an unmaintainable airway requires immediate cricothyroidotomy--a surgical airway placed through the cricothyroid membrane, faster and simpler than tracheostomy in emergencies.
**C.** Nasogastric tube placement has no role in securing a definitive airway; it would not address the airway compromise.
**D.** CPR is indicated for cardiac arrest. This patient has a pulse (102/min) and is breathing--he needs an airway, not chest compressions.