The Collapsed Marathon Runner with an Ambiguous Airway

This is a time-critical presentation where the airway and the probable cause are entangled, so the priority is to secure oxygenation while protecting against aspiration and avoiding worsening a possible heat illness.

1. Remove the improvised collar and reposition. The rolled jacket is flexing the neck and almost certainly contributing to the snoring. Neutral alignment with head tilt–chin lift (no trauma history) is the first, free intervention and frequently converts partial obstruction to a clear airway.
2. Assess and suction if needed. Snoring with accessory use suggests partial obstruction by the tongue and possibly vomit. Suction readiness matters because a marathon runner may have aspirated.
3. Insert an oropharyngeal airway if the patient tolerates it (no gag). If gagging, a nasopharyngeal airway is a reasonable alternative. Reassess after each manoeuvre rather than stacking adjuncts.
4. Ventilate with a bag-valve-mask and high-flow oxygen. Six respirations per minute with accessory use is inadequate minute ventilation; hypoventilation plus hyperthermia is a dangerous combination. Target visible chest rise and a rate appropriate to the clinical picture, avoiding hyperventilation.
5. Consider a supraglottic airway if BVM ventilation is ineffective despite good technique and two-person effort. With 12-minute backup and an 18-minute transport, a failed BVM cannot wait for paramedic support.
6. Do not delay cooling. While airway is the immediate priority, the mechanism (collapse during exertion in heat with hot clammy skin) makes exertional heat stroke a leading differential. Active cooling should begin as soon as it can be done without compromising airway management, because outcome in heat stroke is time-dependent.

The judgement being tested is that airway management and cause-directed treatment are not sequential here; they must be run in parallel without letting one crowd out the other.

This should be rejected on the balance of risk.

The patient is already hypoventilating at roughly 6 per minute with an unprotected airway. Sedation would:

• Further depress respiratory drive and worsen hypercapnia and hypoxia.
• Reduce protective airway reflexes, increasing aspiration risk in a patient who may already have aspirated.
• Remove the patient's remaining muscular tone that is partly maintaining a patent airway.
• Potentially worsen thermoregulation and cardiovascular stability in a suspected heat illness.

The instinct behind the suggestion - that a still patient is easier to ventilate - is understandable, but the correct response to a difficult airway is better positioning, better technique, additional hands, and an appropriate airway adjunct, not pharmacological suppression of a patient who is already barely breathing. Sedation in this context would be a scope and safety error, not a convenience.

• Do not wait for backup if airway and ventilation are achievable now; begin moving toward definitive care while continuing treatment. The 12-minute backup and 18-minute transport mean scene time is the enemy.
• Pre-alert early, not on arrival. State: unresponsive adult, inadequate respirations, suspected exertional heat stroke, airway status and interventions performed, estimated arrival time, and that active cooling is underway. This lets the receiving team prepare airway and cooling resources.
• Continue cooling en route and reassess airway and breathing at intervals; document times and responses.
• Reassess the working diagnosis during transport. If the picture changes (e.g. seizure activity, focal signs, or a history of diabetes or cardiac disease emerges from bystanders), communicate the revision in a second pre-alert rather than letting the first impression harden.

The tested judgement is prioritising definitive care over waiting for a higher skill level when the intervention needed is within your current capability.