Airway management is a core skill of emergency medicine. Physicians in the emergency department must be able to provide definitive resuscitative care to all patients who present with an acute threat to life, including those who need immediate airway management. Some patients present in severe respiratory distress—for example, with airway burns—and require immediate life-saving intervention. Others present with advanced respiratory compromise—for example, in status asthmaticus—when coordinated airway interventions are an essential part of emergency care. Still others present with conditions that appear initially to present no urgent airway threat. However, insidious processes can rapidly create an airway catastrophe. Practitioners must have the skills and knowledge necessary to undertake effective emergency airway management. A methodical approach permits careful evaluation of the patient’s airway for predicted difficulty with intubation, bag-mask ventilation (BMV), surgical airway or all of these. When potential difficulty is identified, the plan must account for the anticipated problems and a back-up plan developed. When airway difficulty is not anticipated, rapid sequence induction using an anaesthetic induction (sedative) drug and a rapidly acting neuromuscular blocker is the preferred approach.

ILLUSTRATIVE CASE

A 45-year-old man known to have severe ankylosing spondylitis is brought to the emergency department (ED) having been struck by a car while crossing the road. He has a minor head injury with a well-preserved level of consciousness and a chest injury with an obvious flail segment affecting the left anterolateral chest wall. Paramedics have placed him on a long spine board with his neck immobilised in a semi-rigid collar and head blocks.

On arrival in the ED he is alert (Glasgow Coma Score (GCS) 15) and complaining of left chest pain and breathing difficulty. He is reasonably comfortable and not asking to sit up. He has no neck pain and is able to move all limbs. Vital signs are: pulse …