1. Initial General Inspection & Bag-Mask Ventilation (BMV) Assessment

  • General Survey:
    • Inspect for contractures, fractures, and obvious skeletal/facial deformities.
    • Assess for presence or risk of cervical spine (C-spine) injury/collar.
    • Inspect external nares for patency (evaluating feasibility of a nasopharyngeal airway).
  • Difficult Bag-Mask Ventilation Predictors (BONES Acronym):
    • B – Beard
    • O – Obesity
    • N – No teeth (edentulous)
    • E – Elderly (age > 55)
    • S – Snores / obstructive sleep apnea (OSA)

2. Focused Airway Examination

  • Dentition & Oral Cavity:
    • Assess for prominent upper incisors.
    • Inspect for dental work (caps, crowns, loose teeth, or dentures).
    • Evaluate tongue size relative to the oral cavity (risk of obstruction/difficulty sweeping during laryngoscopy).
    • Evaluate baseline mouth opening.
  • Mallampati Classification:
    • Technique: Patient sits upright, opens mouth wide, sticks tongue out fully without phonation (do not say “ah”).
    • Class 1: Full visualization of soft palate, fauces, uvula, and tonsillar pillars.
    • Class 2: Visualization of soft palate, fauces, and most of uvula.
    • Class 3: Visualization of soft palate and base of uvula.
    • Class 4: Only hard palate visible (soft palate entirely obscured by tongue base).
  • 3-3-2 Rule:
    • 3 fingers: Inter-incisor distance (mouth opening capacity).
    • 3 fingers: Hyomental distance (from mentum to hyoid bone).
    • 2 fingers: Hyothyroid distance (from hyoid bone to superior notch of thyroid cartilage).
  • Upper Lip Bite Test (Mandibular Protrusion):
    • Step 1: Assess active mandibular protrusion (protruding lower jaw forward).
    • Step 2: Have patient bite upper lip with lower incisors:
      • Class 1: Lower incisors bite upper lip and extend above the vermilion border.
      • Class 2: Lower incisors bite upper lip but cannot clear the vermilion border.
      • Class 3: Lower incisors cannot bite the upper lip.
  • Thyromental Distance:
    • Technique: Patient fully extends neck; measure straight-line distance from thyroid notch to tip of chin (mentum).
    • Normal Threshold: ≥ 7 cm or > 3 finger breadths.
  • Cervical Spine Mobility:
    • Evaluate full extension (looking up at ceiling).
    • Evaluate full flexion (touching chin to chest).

3. Cardiorespiratory Examination

  • Inspection:
    • Signs of respiratory distress: Tachypnea, nasal flaring, tracheal tug, intercostal/accessory muscle use, tripod positioning.
    • Perfusion & Oxygenation: Central cyanosis (lips/mucosa), peripheral cyanosis (digits), and nicotine/tar staining on fingers.
    • Digital clubbing: Presence vs. loss of the Schamroth window.
  • Cardiovascular Auscultation & Palpation:
    • Auscultate precordium for regular rate/rhythm, heart sounds (S1, S2), extra sounds (S3, S4), or murmurs.
    • Additional assessments (if indicated by murmur/findings): Point of maximal impulse (PMI), palpable heaves, or thrills.
  • Respiratory Auscultation:
    • Auscultate bilateral lung fields across anterior, posterior, and lateral zones.
    • Evaluate for quality of air entry and presence of adventitious sounds (wheezes, crackles, stridor).

4. Vascular Access Assessment

  • Venous Assessment (Peripheral IV Access):
    • Apply tourniquet proximal to elbow to induce venous congestion.
    • Inspect and palpate dorsal hand and forearm veins.
    • Adjunct techniques: Vein tapping, traction/taut skin anchoring at knuckles, and warm blankets to promote venodilation.
  • Arterial Assessment (Allen’s Test for Arterial Line Feasibility):
    • Indication: Confirm adequate collateral circulation via ulnar artery before radial cannulation.
    • Technique:
      1. Compress both radial and ulnar arteries simultaneously until hand blanches.
      2. Release ulnar artery compression while maintaining radial compression; verify reperfusion (hand “pinks up”) within normal limits.
      3. Re-compress and repeat release of radial artery to confirm dual supply.

5. Additional Regional Assessments (Procedure-Specific / Neuraxial)

  • Spine & Back Examination:
    • Indication: Pre-procedural evaluation if spinal or epidural anesthesia is planned.
    • Inspection & Palpation: Assess surface landmarks, spine curvature (scoliosis/lordosis), and prior surgical scars.
  • Focused Neurological Baseline:
    • Pre-procedural documentation of baseline motor and sensory function in lower extremities to rule out pre-existing deficits.