A 21-year-old man is brought to the emergency department (ED) after sustaining a close range shot gun blast to the face and neck. He appears intoxicated and has an altered mental status. He intermittently becomes very agitated and combative. He is unable to give a coherent history. His vital signs are as follows: BP 160/10, HR 120, RR 26, temperature 37.8°C. Room air oxygen saturation is 97%. There are numerous pellet wounds to the left side of the face and neck with tissue loss and active bleeding. There is a small hematoma on the left side of the neck and subcutaneous air can be palpated in the region. The larynx can be palpated and appears to be slightly off the midline. When he speaks, his words appeared slurred. It is difficult to ascertain whether his voice is hoarse, but there is no overt stridor. The lungs are clear bilaterally with equal breath sounds. The patient is in need of immediate airway control.

What Is It About Managing the Airway in the ED That Makes It “Different”?

Making critical, lifesaving decisions in the face of incomplete information is fundamental to the practice of emergency medicine. Expert management of the emergency airway is a defining skill of emergency medicine. Emergency physicians must be skilled in all aspects of airway management and must have immediate access to all necessary equipment and medications, including neuromuscular blocking agents. Patients requiring emergency airway management present, often unexpectedly, to the ED. Many of the patients have characteristics associated with difficult intubation and have significant physiologic derangements, but the urgency of the airway problem frequently prevents deferral or even consultation. Frequently, others have already tried and failed to manage the airway, resulting in airway trauma which compounds the difficulty faced by the next practitioner. Accordingly, the emergency practitioner must be both capable and constantly prepared to undertake skilled and timely intervention in patients with compromised airways, and to plan an approach that takes into account all potential difficulties and incorporates within it backup plans (Plan B, Plan C, etc.).

Who Is Primarily Responsible for Managing the Airway in the ED?

Airway evaluation and management is the first priority of resuscitation and establishing a patent airway to maintain oxygenation takes precedence over all other activities. That is not to say that concurrent evaluation and management activities should not occur, it simply says “Do this first!” identifying that the patient requires airway management does not necessarily mandate that the management be undertaken immediately; it simply establishes that early, deliberate airway management is indicated. In some cases, the patient will be apneic with an unprotected airway, and airway management will supersede virtually all other evaluation and management. In other cases, the practitioner will identify that early airway intervention is required, and plan to provide it early during the course of comprehensive and coordinated care.

The emergency physician has final responsibility for ensuring definitive management of the airway for patients presenting to the ED, which might, at times, require the advice and help of other specialists such as anesthesiologists, otolaryngologists, or intensivists.

What Are the Indications for Tracheal Intubation in the ED?

The indications for tracheal intubation in the ED are straightforward:

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  Inability of the patient to maintain or protect the airway

  
  
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  Inability to maintain adequate gas exchange

  
  
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  A predictable clinical deterioration in maintaining the airway or adequate gas exchange

Early establishment of a patent airway and provision of adequate oxygenation are critical to patient survival. Equally important is the ability to predict an impending loss of airway patency or gas exchange capability, particularly if the patient will be subjected to diagnostic studies in areas outside the ED, or transported by land or air to another facility.

Subsequent decisions as to how and when the airway should be managed will depend on numerous factors, including the skills and experience of the practitioner, the equipment available, the condition of the patient, and the anatomy of the airway.

Is There a Conceptual Framework Which the Emergency Physician or Other Consultants Employ in Approaching the Airway in the ED?

It is widely recognized that a conceptual framework focusing on rapid airway evaluation, critical action analysis and performance, and facility with an array of airway management techniques minimizes the risk of failure and improves outcome.¹ To be precise, in an emergency, the airway practitioner must be capable of the following:

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  Rapidly assessing the urgency of the situation and the patient’s need for intervention.

  
  
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  Determining the best method of airway management for the particular circumstances at hand and having a backup plan in the event of failure.

  
  
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  Understanding the risks and benefits of each possible approach.

  
  
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  Optimizing the patient’s cardiopulmonary status before intubation.

  
  
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  Deciding which pharmacologic agents to use, in what order, and in what doses.

  
  
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  Managing the airway in the context of the patient’s overall condition.

  
  
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  Using any of a number of airway devices to achieve a definitive airway while minimizing the likelihood, severity, and duration of hypoxemia or hypercarbia.

  
  
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  Recognizing when the planned airway intervention has failed and an alternative (rescue) technique is required.

  
  
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  Being able to rapidly identify when to call for assistance and what type of assistance might be required.