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An unconscious 19-year-old morbidly obese man is brought into the emergency department (ED) by emergency health services (EHS) paramedics, having been found unresponsive at a fraternity initiation party. He had been drinking heavily, although the amount of alcohol consumed is unknown. The patient is unidentified and there is no available past medical history. Respirations are shallow, and paramedics have inserted a nasal trumpet and an oral airway and are assisting ventilation with a bag-mask. They had attempted oral and nasal intubation three times in the field but failed due to the patient being combative and obesity.

The vital signs are: blood pressure (BP) 114/70 mm Hg, heart rate (HR) 103 beats per minute (bpm), respiratory rate (RR) 8 to 10 breaths per minute and shallow, and oxygen saturation is 92% by assisted bag-mask-ventilation. The patient responds only to pain with purposeful movement. His blow by breath sample for ethanol reads at 220 mg/dL or 47.7 mmol·L−1 and his blood sugar is 90 mg/dL or 5 mmol·L−1. There are no signs of trauma.

In summary, we have no information as to his identity, his history of present or past illnesses, history of allergies or medications, his past medical history, his family or social history, or what or how much might be in his stomach.

20.2.1 What Is It About Managing the Airway in the ED that Makes It "Different"?

Making crucial 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. All necessary equipment and medications, including neuromuscular blocking agents, must be readily available to emergency practitioners who must be skilled in all aspects of airway management. Patients requiring immediate emergency airway management present, sometimes unexpectedly, to the ED. Many of the patients have characteristics associated with difficult laryngoscopy and intubation, 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 trauma and other complications which compound the difficulty faced by the next practitioner. Such issues serve to highlight the importance of the verbal report given by field personnel as they deliver patients to an ED.

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).

20.2.2 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 and oxygenating the brain and vital organs takes precedence over all other activities. That is not to say that concurrent evaluation and management activities should not occur, it ...

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