CHAPTER 22: Airway Management in the Emergency Department

CASE PRESENTATION

A 55-year-old man with a history of diabetes and hypertension presents to the emergency department (ED) with several days of worsening shortness of breath. He saw his primary care provider a week ago and tested positive for SARS-CoV-2. Upon arrival in the ED, he has a blood pressure of 94/52, a heart rate of 136, a respiratory rate of 34, a temperature of 100.9°F and a room air oxygen saturation of 66%. An intravenous (IV) is established and he is given a 1000 mL bolus of crystalloid and a norepinephrine infusion was started. He was placed on high-flow nasal oxygen (HFNO) with an FiO₂ of 100% and a flow of 40 L·min⁻¹. A portable chest X-ray was performed which revealed diffuse patchy alveolar airspace disease.

INTRODUCTION

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 video laryngoscopes, extraglottic devices (EGDs), surgical airway equipment, induction agents, and neuromuscular blocking agents. Patients requiring emergency airway management typically present unexpectedly to the ED leaving little time for preparation and planning. Many of these 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. Accordingly, the emergency physician must be both capable and constantly prepared to undertake skilled and timely intervention in patients in the ED 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 a critically important aspect of resuscitation and establishing a patent airway to maintain oxygenation often takes precedence over all other activities. 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 assistance of other specialists such as anesthesiologists, otolaryngologists, or intensivists.

What Are the Indications for Tracheal Intubation in the ED?