LAS VEGAS—There are eight questions every emergency physician should consider regarding airway management according to Michael A. Gibbs, MD FACEP, professor and chair of the department of emergency medicine at Carolinas Medical Center, Levine Children’s Hospital in Charlotte, North Carolina. He covered each in his Sunday session—noting that it’s a companion lecture to a session covering case studies later in the day and an advanced airway techniques lab on Monday.

Dr. Gibbs said the biggest challenge facing emergency physicians with regard to airway management is that they care for the sickest of the sick with little margin for error. “The collective goal is to achieve first pass success in every patient,” he said.  “We know it’s not achievable 100 percent of the time, but it’s a rule.”

He emphasized that, while some airways are more difficult than others, “there’s no such thing as an easy airway. By definition, all patients requiring urgent intubation are difficult airways,” he said. “Every case needs to be approached with the same level of sophistication and rigor.”

Given the stakes, physicians should preplan to increase chances of first attempt success. This includes rapid assessment skills, preparation, technical proficiency, team communication, calm under pressure, and the ability to anticipate trouble. He suggested asking yourself, “What ‘s going to go wrong in the next five minutes?”

Failed airways in the emergency department are rare (2.7 percent according to one study). That said, the average emergency physician has limited “rescue experience.” To make matters worse, in a rescue situation, there will be very little time. When assessing an airway, physicians should consider if intubation is required. Will it be difficult? What is the best technique? Will physiology suffer? And, importantly, what is the best rescue strategy? Most physicians consider the first three questions, said Dr. Gibbs, “often we forget about those last two.” The goal is to prevent hypoxia and hypotension post–intubation.

He urged attendees to consider pre-oxygenation to prevent desaturation during emergency airway management. “Every patient you intubate from now to the end of your career should get apneic oxygenation,” Dr. Gibbs said. For more information, he suggested all attendees read the 2012 study in the Annals of Emergency Medicine by Scott D. Weingart, MD.

While first attempt success rates are a reported 83 percent—largely due to the increased use of video laryngoscopy—there is still work to be done, said Dr. Gibbs. Limited mouth opening is still a predictor of difficulty, but he suggests patient positioning can improve success. Rather than placing the patient in a sniffing position, he said that keeping the patient’s head flat improves visibility, particularly in morbidly obese patients.

For those few cases where the airway fails, all physicians should have a menu of rescue devices on hand at the bedside. Just having the devices at the ready isn’t enough, said Dr. Gibbs. Practice, practice, practice.

To reduce the risk of post-intubation hypotension, Dr. Gibbs said physicians must be on the lookout for shock.  A Shock Index of greater than 0.8 is the most important predictor of a poor outcome, he noted. He also recommended slowing ventilation for resuscitated patients. “Bag the patient slowly,” he said.

For Dr. Gibbs, the take home essentials include meticulous preparation, acknowledgement that all ED intubations are high risk and a thorough assessment of anatomy and physiology. “In my view, physiology carries the day,” he said. Dr. Gibbs also emphasized becoming an expert at pre-oxygenation.

Teresa McCallion is a freelance medical writer based in Washington State.