Emergency airway management: an EUSEM statement with regard to the guidelines of the Society of Critical Care Medicine

Introduction

Emergency airway management (EAM) is a complex task. Manual skills needed for EAM are learned through practice and need to be maintained with regular training.

Patients and their conditions are usually completely unknown, the administration of drugs for the procedure with all the potential side effects must be induced promptly, although conditions are not optimal.

Recently, the Society of Critical Care Medicine (SCCM) published practice guidelines for EAM of critically ill patients [1]. In this viewpoint, we aim to briefly and critically examine the recommendations and identify further necessary action points. These are the key points that we also convey to emergency physicians and paramedics in the EAM Course of the European Society of Emergency Medicine (EUSEM).

Recommendations

The first four of our recommendations were not mentioned by the SCCM, yet we consider training, checklists, team composition and an explicitly discussed plan for failure before EAM as essential steps of EAM.

Training

We recommend that all team members regularly involved in EAM undergo airway courses. These courses must encompass not only manual competencies but also cognitive and mental strategies.

Checklists

We recommend using checklists for the preparation and conduction of EAM, as they have been shown to help to reduce complications in emergency anesthesia [2].

Team composition

For EAM, we recommend a team of at least two emergency physicians and two nurses, more if possible at the beginning, with preallocated roles within the team. All emergency physicians must be proficient in EAM, including emergency front-of-neck access. Additionally, a team for advanced airway management in the case of anticipated or unexpected difficulties should be available.

Plan for failure

We recommend that for every emergency anesthesia/EAM, alternative airway options like different supraglottic airways should be discussed and prepared within the team. This includes to be ready to perform an emergency front-of-neck access as well as fiberoptic intubation.

Positioning

The semi-Fowler position, recommended by the SCCM, cannot be generally recommended for emergency intubation, as not all patients can be placed in this position. This is especially true for the prehospital setting, but also in cases of conditions with manifested shock or ongoing resuscitation, which can make an upright position impossible or medically unfeasible. Although this positioning can be favorable in many situations, we recommend training for so-called ‘situational difficult airways’. Examples of situational difficult airways are ongoing chest compressions or trauma patients where c-spine immobilization is required.

Nasogastric tube decompression

We consider the SCCM recommendation of nasogastric tube placement before induction an additional step with very limited evidence and rare indications, which might distract from more sound steps in the resuscitation process prior induction.

Preoxygenation

Whereas the SCCM recommendation regarding preoxygenation is dependent on the severity of hypoxia, we recommend to optimize preoxygenation by either using high-flow nasal oxygen or, if no contraindications exist, delayed sequence intubation using noninvasive positive-pressure ventilation [3–5]. Similar to optimal preoxygenation in the operating room, this should be mandatory in the emergency department as well. Pharmacologically assisted preoxygenation may be necessary due to agitation, under these circumstances we primarily recommend the use of Ketamine with its properties of preserving respiratory drive and being relatively hemodynamically stable [5].

Apnoeic oxygenation

Apnoeic oxygenation is not routinely recommended by the SCCM but should be used whenever possible for prolongation of safe apnea times [3,6].

Peri-intubation vasopressors

Hypotension is a common complication during the peri-intubation period in critically ill patients. Therefore, and in contrast to the SCCM statements, we strongly recommend vasopressors during the peri-intubation period, especially in septic or bleeding patients or those who are dehydrated, like exhausted asthma patients. As the SCCM states, evidence for i.v.-fluids in terms of preventing hypotension is not convincing [7].

Induction agent and neuromuscular blocking agents use

Recommendations of the SCCM regarding induction agents and neuromuscular blocking agents leave room for speculation. Propofol has pronounced hypotensive properties, especially when combined with opioids. Therefore, we explicitly do not recommend Propofol for critically ill patients due to the availability of better alternatives [8]. Both etomidate and ketamine have nearly hemodynamically neutral properties, with etomidate potentially causing adrenal suppression [9,10]. Therefore, our recommendation is to combine ketamine with rocuronium (‘Rocketamine’). Given the high therapeutic index of both drugs, a simple and easily rememberable dose of 100 mg each may be a practical approach for inducing emergency anesthesia for most patients, keeping in mind that rocuronium requires high dosages for quick relaxation. In peri-arrest states, neuromuscular blocking agents might be considered as monotherapy, although the combination with low-dose ketamine is probably a better choice for ethical reasons.

The SCCM guidelines do not cover videolaryngoscopy, bougie, prepared suction, end-tidal CO₂, postintubation period and quality management—which in our opinion need to be acknowledged.

Videolaryngoscopy

For optimal first-pass success we recommend standard-geometry-videolaryngoscopy, as the primary strategy for most emergency intubations [11,12]. Furthermore, for the sake of simplicity, we recommend the use of the so-called midline approach [13].

Bougie-assisted intubation

For the best first-pass success, we generally recommend the use of a bougie as part of the primary intubation strategy [14].

Suction catheter

We recommend routinely preparing for massive regurgitation during EAM by keeping a large-bore suction catheter at hand and training the Suction-Assisted Laryngoscopy and Airway Decontamination technique [15].

End-tidal CO₂

We strongly recommend continuous end-tidal EtCO₂ measurement during any assisted ventilation.

Postintubation period

We recommend ensuring continuous monitoring of vital signs, including end-tidal CO₂ and sedation levels. Any complications, such as hypotension, hypoxemia or difficulties with ventilation should be managed immediately.

Conclusion

Recently, several studies have led to an improved evidence base regarding EAM. We advocate that emergency physicians take responsibility for EAM and are the primary individuals to carry it out. EAM courses should include theoretical, practical and mental-cognitive content. We consider three things to be crucial: prevention of desaturation, prevention of hypotension, and a high first-pass success rate. We also consider mental and cognitive training as an essential part of education.

Acknowledgement

Conflicts of interest

There are no conflicts of statement.