The Pitchside Airway

The classic teaching is the tongue, and it is not wrong. In an unconscious athlete lying supine it does fall back, a jaw thrust does fix it, and that is worth knowing. It is simply not the whole of what you will meet.

Contamination is the other half. A mouthguard sitting in the mouth of a player who has just been knocked out. Blood from a facial injury pooling at the back of the throat. A broken tooth. Vomit, which is common after a head injury and is why nobody with a reduced conscious level lies on their back unattended. Remove what is clearly visible and readily reachable, and nothing else. Blind finger sweeps are not done, and neither is hunting for something you cannot see.

Listen, because the noise tells you which problem you have. Snoring is the tongue. Gurgling is fluid. Stridor is an airway narrowing, and it will not wait for you.

Then look at the face and neck. Stridor, progressive swelling of the face or neck, or an unresponsive athlete all mean 999 now and urgent advanced airway support moving towards you. These are airways that are closing rather than blocked, and your bag is not the answer to them.

Hands first. Position the athlete, then open the airway with a jaw thrust where spinal injury is suspected from the mechanism or the examination, or with a head tilt and chin lift where it is not. Nothing here comes out of a bag.

If a jaw thrust with in-line stabilisation does not open it, you accept some movement of the neck to open the airway, adding a head tilt and chin lift as needed to achieve patency. Airway opening takes priority over minimising cervical movement, and an obstructed airway above a perfectly held neck is not a success.

Then clear what you can see, and use suction where it earns its place: visible blood, vomit or secretions in the upper airway, with a wide-bore device, by somebody trained to use it. Use it carefully where the gag reflex is intact, because suction provokes vomiting, which is the problem you were trying to solve.

Then the adjuncts. An oropharyngeal airway holds the tongue forward and needs an athlete with no gag reflex; if they gag on it, take it out. A nasopharyngeal airway is tolerated at a lighter level of consciousness. Both are sized to the athlete rather than to a rule of thumb, and both need the airway reassessed once they are in, because an adjunct can obstruct as readily as it relieves.

Where a base of skull fracture or significant mid-facial injury is suspected, prefer an oral airway if you can. The concern with the nasal route is intracranial passage, and although that risk is small, the oral route avoids the question entirely. Airway patency remains paramount: if the oral route will not work and the athlete needs an airway, the airway still wins.

Then supraglottic devices, an i-gel or similar. They support ventilation in a deeply unconscious athlete with no airway reflexes, most often during resuscitation, and they arrive with everything that goes around them: effective bag ventilation, and appropriate monitoring. Placing the device is not the intervention; it is part of one.

Then intubation and a surgical airway. For almost everyone the ladder stops well below here, and it should.

An unresponsive athlete means a 999 call, and it goes out before or alongside your assessment of their breathing rather than once you have made your mind up.

Position is treatment and it is free. An athlete with a reduced conscious level who is breathing normally and does not meet the criteria for resuscitation goes into a lateral recovery position, which keeps the tongue forward and lets fluid drain out rather than down.

Two exceptions matter and they are the ones people get wrong. Agonal breathing is not breathing, so an athlete showing it does not go into the recovery position; they get compressions. And in trauma the athlete is not rolled into the recovery position either, because there is a spine in the equation. If the airway genuinely needs them turned, that is a controlled log roll with the neck held in line, and it is the airway that justifies it.

Never force an uncooperative athlete into a position, because forcing them may worsen an injury. But do not read the fight as reassurance either. Agitation is information, and an athlete resisting you may be hypoxic or have a brain injury, which is a reason to look harder rather than to relax.

Where the airway and the cervical spine genuinely conflict, the airway wins. Opening it takes priority over in-line immobilisation, and a jaw thrust should maintain a neutral neck while you do it.

And the honest part. Plenty of pitchside clinicians carry a supraglottic device they will never place. The ladder describes what exists; it is not a list of what you should own. Your rung is the highest one you are currently competent, equipped, governed and practised to perform, and none of those is a certificate in a drawer.

• •Current Resuscitation Council UK first aid guidance covers airway opening, calling 999 for an unresponsive person, the recovery position and its exceptions in agonal breathing and trauma, and the principle that you use only equipment you have been trained to use.
• •The same guidance states that airway opening takes priority over in-line immobilisation where the two conflict, and that a jaw thrust should maintain a neutral position of the neck.
• •Resuscitation Council UK's advanced life support guidance covers supraglottic airway use within resuscitation, alongside the ventilation and monitoring that accompany it.
• •The Faculty of Pre-Hospital Care endorses immediate care in sport courses. Endorsement confirms curriculum content and educational quality; what an individual may do depends on their current competence, governance, equipment and maintained practice.

• •Common pitchside causes of obstruction include a mouthguard, blood, teeth and vomit.
• •Snoring is the tongue, gurgling is fluid, and stridor is an airway that is narrowing.
• •If a jaw thrust does not open it, add a head tilt and chin lift as needed; airway patency outranks cervical precautions.
• •An oropharyngeal airway needs no gag reflex, and comes out if the athlete gags.
• •Prefer an oral airway where a base of skull fracture is suspected, but the airway still wins.
• •Do not use the recovery position in agonal breathing or in trauma.