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CASE PRESENTATION

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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.

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INTRODUCTION

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

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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.).

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

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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 ...

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