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The airway management of unstable and critically ill patients has always been an essential skill within the emergency physician's scope of practice. The early act of inserting an artificial airway protects the lungs from aspiration in an obtunded patient, or prevents hypoxia and carbon dioxide retention in a patient who cannot spontaneously breathe. This has been shown to improve neurologic outcome when performed early during the initial phase of resuscitation, and emergency physicians are often the first clinicians to perform intubation and initiate mechanical ventilation.1

While direct laryngoscopy is associated with a high rate of success with few adverse events when performed by personnel skilled in its use, there are a number of clinical scenarios and presentations in which direct or indirect laryngoscopic intubation is difficult or impossible. Disruption of the normal anatomy due to body habitus, medical and surgical disease, or facial and oral trauma can result in soft-tissue and bony structure distortion. Obstruction or lack of laryngeal visualization can be caused by copious amounts of blood or vomitus, facial edema, vocal cord swelling from prolonged or multiple intubation attempts, anaphylaxis, angioedema, and burns.

When an emergency physician is called upon to perform urgent airway management, the approach to airway management should be standardized and similar in all contexts. Whether in the field with an emergency medical services (EMS) agency or in the hospital, a clinician should recognize when to abort further attempts at intubation through direct visualization and proceed to alternative techniques for establishing an artificial airway. As discussed in the preceding chapter, inability to identify the vocal cords should prompt the use of a “difficult airway” algorithm that includes the use of intubation adjuncts such as tracheal tube introducers, alternative intubation devices such as video laryngoscopes, flexible fiberoptic scopes, lighted stylets, retrograde approaches, or the placement of a laryngeal mask airway (LMA).

When intubation is not successful, especially after administration of neuromuscular blockade, and when adequate oxygenation or ventilation with the bag–valve–mask technique cannot be achieved, a “failed airway” has occurred. At this point, cricothyroidotomy is the emergency medicine surgical airway of choice.2,3 It should be noted that the terms cricothyroidotomy and cricothyrotomy are synonymous and may be used interchangeably.

Fortunately, the incidence of the “failed airway” in the emergency department (ED) setting is low. Depending on the patient population and the skill level of the clinician, airway management databases report the use of a surgical airway in 0.03% to 1.8% of patients who require definitive airway management.48 When it does occur, a “failed airway,” sometimes referred to as a “cannot intubate–cannot ventilate” situation, requires a surgical airway be placed immediately. Unfortunately, when required, the establishment of an emergency surgical airway is associated with a high rate of complications, up to 14% in some reviews.9

Despite newer equipment and modified approaches, there remain two traditional ...

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