Difficult Airway Management in the Emergency Department
Managing a difficult airway in the ED requires rapid, structured decision‑making, standardised preparation and immediate access to rescue options. ED patients are often physiologically unstable and present with dynamic pathology (blood, vomit, swelling, trauma) that increases the risk of failed airway attempts.
Departments must therefore be organised so clinicians can prioritise oxygenation and minimise harm (RCEM/RCoA joint statement).
Why ED airways are different
- Pathology (maxillofacial trauma, burns, angioedema, haemorrhage, infection) and physiology (hypoxaemia, agitation, decreased consciousness) frequently complicate airway management.
- There is limited time for assessment and optimisation; the first operator may be less experienced.
- Specialist support or specific devices may not be immediately available unless systems are set up to provide them.
Clinical assessment (rapid, pragmatic)
Use a combination of bedside checks rather than relying on a single test - predictions are imperfect but help plan.
- Predictors of difficult bag‑valve‑mask (BVM) ventilation (commonly summarised as MOANS):
- Mask seal - poor seal from facial hair, trauma, blood or oedema.
- Obesity or upper airway obstruction.
- Age (reduced tissue compliance and dentition changes).
- No teeth - poor mask fit.
- Stiff lungs - reduced compliance (e.g., ARDS, pulmonary oedema).