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20.3.1 How Did Airway Management in the ED Evolve to Where It Is Today?
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Emergency airway management for much of history consisted of various forms of back-pressure/arm-lift artificial respiration, or mouth-to-mouth, mouth-to-nose, and bag-mask-ventilation (BMV) by minimally trained providers until the 1960s when resuscitation research identified airway management failure as a crucial issue affecting outcome.2-5 By the early 1970s, endotracheal intubation was recognized as an essential part of the skill set for physicians providing emergency care, but most physicians staffing emergency departments were trainees or practicing physicians with little or no formal training in emergency medicine. Intubation was generally accomplished without neuromuscular blocking agents, using either the oral or the nasal routes, sometimes requiring heavy sedation before airway management could be attempted. Intubation using a sedative, such as a benzodiazepine, often accompanied by an opioid, such as morphine, became a common practice despite its frequent failures and complications.
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The advent of emergency medicine residency training programs in 1969 and the rapid growth of the specialty through the ensuing two decades established a large cadre of trained emergency medicine specialists and led to the rapid deployment of neuromuscular blockade to facilitate orotracheal intubation. By the late 1980s, the use of neuromuscular blockade for this purpose was well established in emergency medicine residency training programs, and had been dubbed "rapid sequence intubation" (RSI) in distinction to the anesthesia term "rapid sequence induction."6 By the mid to late 1990s, neuromuscular blockade was widely used and it became evident that neuromuscular blockade not only made the technical task of intubation easier and faster, but also resulted in greater success with lower complication rates.6
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However, a need clearly emerged for a consistent framework to identify patients at risk for difficult and possibly failed laryngoscopy and intubation, to develop a reliable approach to such patients, and to expand the rescue options beyond the single choice of cricothyrotomy.
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The challenges facing emergency airway practitioners today include:
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Restricting the use of neuromuscular blockade only to patients in whom there is a strong likelihood that tracheal intubation will be successful or that gas exchange can be maintained by some other technique in the event of failure
Selecting an alternative approach for those patients in whom a difficult or impossible intubation may be anticipated
Ensuring the success for alternative rescue devices or techniques in the event of intubation failure