Evaluation and Management of the Difficult Pre-Hospital Airway

  • Janis P. Tupesis
  • Nathan Van Dyk


Airway management in the pre-hospital setting poses a unique set of challenges. While elective management of a patient’s airway is typically performed in a controlled environment by experienced clinicians, circumstances in the pre-hospital setting are often much different than that in the operating room or even the Emergency Department. As seen in Figs. 15.1 and 15.2, patient care happens in a wide variety of surroundings including accident scenes, private residences, and in Emergency Medical Service vehicles. Often, there are challenges to the rapid establishment of an adequate airway in ill or injured patients. This can include entrapped or difficult to access patients, unsafe or hostile settings, and psychomotor challenges such as having to perform procedures in the back of a moving ambulance or helicopter. In addition, pre-hospital airway management often happens in the setting of an acute, decompensated medical condition coupled with an increased risk of regurgitation with impaired protective reflexes. In contrast to the controlled inpatient location, patients are frequently in a state of cardiovascular collapse, respiratory distress, or suffering from polytrauma. It is estimated that difficult intubating conditions are encountered in approximately 7–10 % of patients requiring airway management in the pre-hospital setting [1, 2]. It is unclear whether these numbers are truly reflective of the dimension of the problem. In recent studies evaluating the incidence of adverse events during pre-hospital airway management by paramedics in patients with severe head injuries, it was noted that complications frequently occur. In one study, 31 (57 %) of 54 patients demonstrated desaturation during rapid sequence intubation (RSI). Six (19 %) patients experienced marked bradycardia (HR <50 beats/min) during these desaturation events [3]. It is in this context that we wish to discuss the evaluation, approach, and management of the difficult airway.


Emergency Medical Service Airway Management Difficult Airway Helicopter Emergency Medical Service Emergency Medical Service System 
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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  2. 2.Emergency DepartmentVista East Medical CenterWaukeganUSA

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