**2. Incidence**

While the frequency of difficult intubation in operating rooms is 1.15% –3.8%, this rate varies between 3.0% and 5.3% in the emergency department [2]. Difficult intubation significantly decreases the success rate of the first attempt. The risk of complications accompanies this condition. Therefore, difficult airway management preparation should be performed effectively.

Accidents can cause airway complications. Tracheobronchial injury is one of the least common injuries in blunt chest trauma, but it has a high mortality rate. Approximately 81% of the patients die at the accident site or before reaching the emergency department [3]. Pneumothorax, pneumomediastinum, atelectasis, and subcutaneous emphysema can be seen in radiological imaging. Surgical airway incidence has been reported to be 0.1–7.7% [4].


#### **Table 1.**

*Pearls of airway management in the emergency room.*

#### **3. Airway providing methods**

Airway management in emergency medicine requires skills and equipment. The Rapid-sequence intubation (RSI) technique is used in the rate of 99% for tracheal intubations performed under emergency conditions [5]. RSI consists of sedation, analgesia, and muscle paralysis components. For this purpose, rocuronium or succinylcholine is used as a muscle relaxant. Rocuronium is increasingly in use due to its advantages such as rapid onset effect, minimal side effects, greater availability than succinylcholine, and rapid reverse ability using sugammadex. In a retrospective study of 215 patients, West et al. [6] reported that rocuronium was chosen to provide muscle relaxation predominantly in the patient group with higher early mortality. The use of rocuronium in this study resulted in hypoxemia more often before RSI and VL. A recent large observational study reported no difference in first-pass success rate and intubation-related adverse events between the use of succinylcholine and rocuronium for RSI in the emergency department [7].

Airway management in emergency conditions is complicated due to several factors including facial and neck trauma, risk of vomiting and aspiration, cervical spinal immobilization, or chest compressions applied for resuscitation. It decreases the success of intubation. During difficult tracheal intubation, prolonged apnea results in a sudden decrease in pH, hemodynamic collapse, dysrhythmia, and bradycardia. PaO2 decreases as oxygen are suspended from the lungs. Therefore, effective preoxygenation should be performed before the procedure, and apneic oxygenation should be considered throughout the procedure to lengthen the

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**Figure 1.**

*Airway Management in Accident and Emergency DOI: http://dx.doi.org/10.5772/intechopen.96477*

the viewing angle.

**4. Psychological barriers**

apneic window. Recommended preoxygenation techniques include tidal volume ventilation for 3 min with high FiO2, 8 min ventilation with 100% FiO2, or oxygen inhalation until etO2 reaches 90% and above [8]. Low flow or high flow oxygen is used for apneic oxygenation. Insufflation can also be performed through the venturi mask, nasal cannula, and oxygen cannula or catheters. However, oxygen up to 15 L/min can be given with these techniques. FiO2 can be given in the range of 0.21-1 with 60-70 L/min flow through high flow systems. In these systems, it is possible to reach high flow rates as oxygen is given by humidifying and heating [9]. The manual inline stabilization (MILS) technique is used in patients with cervical trauma, and direct laryngoscopy worsens the vision in 50% of the cases [10]. C-spine collars and MILS limit the mouth opening. The use of videolaryngoscopes during MILS increases the first attempt success rate by increasing

Psychological barriers complicate emergency airway management. This situation causes delays in the application of invasive techniques such as emergency cricothyroidotomy. The Vortex Approach has been defined to increase airway management's success rate applied under emergency conditions [11, 12]. It evaluates the steps of airway management in two parts as preparation and implementation. On the one hand, it is aimed to provide oxygenation successfully without the need for surgical techniques (**Figure 1**). On the other hand, invasive techniques are prepared before the patient is desaturated. Vortex provides effective teamwork. It is thought that this

approach can increase the clinical applicability of difficult airway guidelines.

*The Vortex Approach action plan available from: http://vortexapproach.org*.

*Airway Management in Accident and Emergency DOI: http://dx.doi.org/10.5772/intechopen.96477*

*Special Considerations in Human Airway Management*

frequently accompanying acidosis should be treated.

These include chin lift, jaw thrust, recovery position.

2. Effective preoxygenation should be applied.

obstructive pulmonary disease.

poor outcome.

sharing the work.

training.

**Table 1.**

**3. Airway providing methods**

*Pearls of airway management in the emergency room.*

Airway management in emergency medicine requires skills and equipment. The Rapid-sequence intubation (RSI) technique is used in the rate of 99% for tracheal intubations performed under emergency conditions [5]. RSI consists of sedation, analgesia, and muscle paralysis components. For this purpose, rocuronium or succinylcholine is used as a muscle relaxant. Rocuronium is increasingly in use due to its advantages such as rapid onset effect, minimal side effects, greater availability than succinylcholine, and rapid reverse ability using sugammadex. In a retrospective study of 215 patients, West et al. [6] reported that rocuronium was chosen to provide muscle relaxation predominantly in the patient group with higher early mortality. The use of rocuronium in this study resulted in hypoxemia more often before RSI and VL. A recent large observational study reported no difference in first-pass success rate and intubation-related adverse events between the use of succinylcholine and rocuronium for RSI in the emergency department [7].

1. Patients with increasing respiratory failure should be evaluated frequently. The underlying causes of

4. Since ketamine has bronchodilator effects; it should be considered in the induction of patients with

5. The presence of conditions such as hypoxemia, hypercapnia, and acidosis that increase Pulmonary

6. First of all, airway clearance should be provided and maintained with basic airway management tools.

9. RSI should be considered for tracheal intubation, while care should be taken against the risk of hemo-

10. Direct or indirect laryngoscopy can be applied. However, video-laryngoscopes have some advantages. 11. Tracheal intubation should be confirmed by capnography. Postintubation hypocapnia is associated with

12. Oxygenation with tracheal intubation, laryngeal mask, and bag valve mask should be tried before invasive techniques such as surgical airway. However, in case of failure, cricothyrotomy should not be delayed. 13. Airway management should be provided with teamwork, and critical situations should be overcome by

15.It should be ensured that the acquired knowledge and skills are made permanent by planning periodical

14.Recommendations for difficult airway guidelines should be transferred to clinical practice.

3. Apneic window duration should be extended with apneic oxygenation techniques

8. Suction should be used to prevent aspiration of secretions, mucus, or vomit residues.

Vascular Resistance should be avoided in patients with cardiac disease.

7. The oral or nasal airway should be used in an unconscious patient.

dynamic deterioration, prolonged apnea, and pulmonary aspiration.

Airway management in emergency conditions is complicated due to several factors including facial and neck trauma, risk of vomiting and aspiration, cervical spinal immobilization, or chest compressions applied for resuscitation. It decreases the success of intubation. During difficult tracheal intubation, prolonged apnea results in a sudden decrease in pH, hemodynamic collapse, dysrhythmia, and bradycardia. PaO2 decreases as oxygen are suspended from the lungs. Therefore, effective preoxygenation should be performed before the procedure, and apneic oxygenation should be considered throughout the procedure to lengthen the

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apneic window. Recommended preoxygenation techniques include tidal volume ventilation for 3 min with high FiO2, 8 min ventilation with 100% FiO2, or oxygen inhalation until etO2 reaches 90% and above [8]. Low flow or high flow oxygen is used for apneic oxygenation. Insufflation can also be performed through the venturi mask, nasal cannula, and oxygen cannula or catheters. However, oxygen up to 15 L/min can be given with these techniques. FiO2 can be given in the range of 0.21-1 with 60-70 L/min flow through high flow systems. In these systems, it is possible to reach high flow rates as oxygen is given by humidifying and heating [9]. The manual inline stabilization (MILS) technique is used in patients with cervical trauma, and direct laryngoscopy worsens the vision in 50% of the cases [10]. C-spine collars and MILS limit the mouth opening. The use of videolaryngoscopes during MILS increases the first attempt success rate by increasing the viewing angle.
