Viewpoint 83
Emergency airway management: an EUSEM statement with
regard to the guidelines of the Society of Critical Care Medicine
Christian Hohensteina, Sabine Merzb, Fabian Epplerc, Volkan Arsland,
Bariş Murat Ayvacie and Luca Ünlüf; for the European Society for Emergency
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Medicine
European Journal of Emergency Medicine 2024, 31:83–85
a
Department of Emergency Medicine, Zentralklinik Bad Berka, University of
Marburg, Faculty of Medicine, Bad Berka, bRed Cross Villingen-Schwenningen,
Villingen-Schwenningen, cFaculty of Medicine, University of Mainz, Mainz, Germany,
d
Department of Emergency Medicine, Hacettepe University Medicine Faculty,
Ankara, eDepartment of Emergency Medicine, University of Health Sciences Prof.
Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey and fFaculty of Medicine, Karl-
Landsteiner University of Health Sciences, Krems a.d. Donau, Austria
Introduction
Emergency airway management (EAM) is a com-
plex task. Manual skills needed for EAM are learned
through practice and need to be maintained with reg-
ular training.
Patients and their conditions are usually completely
unknown, the administration of drugs for the proce-
dure 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 crit-
ically 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 men-
tioned by the SCCM, yet we consider training, check-
lists, 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 cog-
nitive and mental strategies.
This is an open-access article distributed under the terms of the Creative
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without permission from the journal.
0969-9546 Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.
Correspondence to Christian Hohenstein, MD, Department of Emergency
Medicine, Zentralklinik Bad Berka, University of Marburg, Robert Koch Allee 9,
99347 Bad Berka, Germany
Tel: +49 36458 542009; e-mail: christian.hohenstein@zentralklinik.de
Received 16 November 2023 Accepted 16 November 2023.
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 emer-
gency physicians and two nurses, more if possible at the
beginning, with preallocated roles within the team. All
emergency physicians must be proficient in EAM, includ-
ing emergency front-of-neck access. Additionally, a team
for advanced airway management in the case of antici-
pated or unexpected difficulties should be available.
Plan for failure
We recommend that for every emergency anesthesia/
EAM, alternative airway options like different supraglot-
tic 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 intu-
bation, 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 impossi-
ble or medically unfeasible. Although this positioning can
be favorable in many situations, we recommend training
for so-called ‘situational difficult airways’. Examples of sit-
uational 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
DOI: 10.1097/MEJ.0000000000001114
 84 European Journal of Emergency Medicine 2024, Vol 31 No 2
very limited evidence and rare indications, which might
distract from more sound steps in the resuscitation pro-
cess prior induction.
Preoxygenation
Whereas the SCCM recommendation regarding pre-
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oxygenation 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 opti-
­ the use of the so-called midline approach [13].
mal preoxygenation in the operating room, this should
be mandatory in the emergency department as well.
Pharmacologically assisted preoxygenation may be nec-
essary due to agitation, under these circumstances we
primarily recommend the use of Ketamine with its prop-
erties 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 rec-
ommend 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 prevent-
ing hypotension is not convincing [7].
Induction agent and neuromuscular blocking agents
use
Recommendations of the SCCM regarding induc-
tion agents and neuromuscular blocking agents leave
room for speculation. Propofol has pronounced hypo-
tensive properties, especially when combined with
opioids. Therefore, we explicitly do not recommend
Propofol for critically ill patients due to the availa-
bility of better alternatives [8]. Both etomidate and
ketamine have nearly hemodynamically neutral prop-
erties, with etomidate potentially causing adrenal sup-
pression [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 relaxa-
tion. In p ­ eri-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
Bougie-assisted intubation
For the best first-pass success, we generally recommend
the use of a bougie as part of the primary intubation strat-
egy [14].
Suction catheter
We recommend routinely preparing for massive regurgita-
tion 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 diffi-
culties with ventilation should be managed immediately.
Conclusion
Recently, several studies have led to an improved evi-
dence base regarding EAM. We advocate that emergency
physicians take responsibility for EAM and are the pri-
mary individuals to carry it out. EAM courses should
include theoretical, practical and m­ ental-cognitive con-
tent. 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.
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