Resuscitative airway management in the emergency department (ED) is inherently difficult by definition, and the practitioner should always be prepared for a difficult airway especially given the relatively poor test characteristics regarding difficult airway predictive tools.

• Preparation for a difficult airway should include:
  • Careful consideration of pharmacology in relation to RSI and consideration of awake intubation if there are no contraindications including an uncooperative patient or altered level of consciousness.
  • An extraglottic device should be ready for use.
  • A bougie should be open and directly accessible.
  • An alternative intubation device (video or direct laryngoscopy) should be prepared;
  • A call for assistance should be made;
  • Optimization of oxygenation should be performed using Bag Mask Ventilation (BMV) or positive pressure device and high flow nasal prongs.
  • The neck should be palpated and marked in preparation and prediction of possible surgical airway intervention and
  • All associated tools (primary, supraglottic, surgical) should be ready and open.
  • Once encountered a firm plan and interventions with the resuscitation team engaged (however large or small) must be performed. See below algorithm “The Encountered Difficult Airway”.
• Optimization of BMV starts with patient positioning (if not contraindicated), confirmation of oxygenation source and use of high flow nasal prongs conjointly (for at least 3 minutes if time allows).
• BMV is best performed using oral airway, nasal trumpets, two-person technique, obviation of oral/pharyngeal foreign body and jaw thrust in conjunction with early use of a supraglottic device.
• Second and third attempts at laryngoscopy must include optimization and augmentation/change in technique including use of bougie, external laryngeal manipulation, use of Direct Laryngoscopy or Video Laryngoscopy and intubation by the most experienced airway practitioner.
• If cricoid pressure had been used in the context of a rapid sequence intubation (RSI) then it should be discontinued.

CLICK TO ENLARGE

1. Difficult Airway Society Guidelines – accessed July 25, 2017.

   
   

2. AIME Airway Interventions and Management in Emergencies – accessed July 25, 2017.

   
   

3. The above image of Difficult Airway Algorithm is used with permission. Source:

   Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675-94, with permission from Blackwell Publishing Ltd.

   
   

4. Airway Management in Emergencies – Open-access online textbook from www.aimeairway.ca.

   
   

1. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Society intubation guidelines working group British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371.

   
   

2. Airway Management in Emergencies, Aug 1 2011, George Kovacs,  J. Adam Law, et al. Chapter 12. Approach to an Encountered Difficult Airway, pp 253-298, McGraw-Hill Europe; 2 edition.