To begin, the patient is left in an upright position. Standard pre-oxygenation and preintubation preparation are performed. The physician then approaches the patient face-to-face. As opposed to traditional intubation, the laryngoscope is held in the right hand and the endotracheal tube (ETT) is held in the left. This is to prevent crossing of arms while attempting to pass the ETT. The laryngoscope is held with the curved blade superior to the handle, resembling how one would hold a pickaxe (or tomahawk). The blade is then carefully inserted into the oral cavity and progressed posteriorly. During this progression, gentle traction is applied to the handle, thrusting the mandible anteriorly. Laryngoscope manipulation should be similar to that of supine intubation, avoiding “rocking” at wrist, and being cognizant of dentition. One the epiglottis and vallecula are visualized, the ETT is progressed with the left hand until the ETT is just superior to the vocal folds. At this point, the physician may intubate and immediately start sedation. Alternatively, if it is too challenging to pass ETT through vocal cords, a sedative and paralytic agent can be administered immediately before advancing the ETT. It should take seconds to pass the ETT once properly positioned, making it safer to administer medications that decrease respiratory drive.

There are several special considerations while performing a tomahawk intubation. It is crucial to have additional airway specialists at bedside, if available. Identifying anatomy and preparing equipment for rapid cricothyrotomy should also be a priority. The patients that benefit most from tomahawk intubation are also most dependent on an increased respiratory drive to maintain ventilation and oxygenation. Agents that minimally effect respiratory drive, such as ketamine or dexmedetomidine, may be preferred.^9,10 Glycopyrrolate has been used to help minimize airway secretions.³ A video laryngoscope is the preferred tool for glottic visualization. While a standard, direct laryngoscope can be used, it is much more difficult. If only a direct laryngoscope is available, a two-operator technique can be used. In this case, one operator inserts and manipulates the laryngoscope. The second operator used a flexible laryngoscope with a pre-loaded ETT to visualize the glottis and pass the ETT. If additional help is available, having a team member provide jaw thrust or tracheal pressure may provide better visualization.

Tomahawk intubation is an effective alternate approach to airway management in patients that cannot assume a supine position. While studies are limited, there are encouraging findings that tomahawk intubation is easier to learn than supine intubation, and both techniques have similar time to intubation.^2,7 When managing UAO, consider tomahawk intubation to secure a difficult airway.