ER Basics for Rookies

Most intubations in the ED allow at least a few minutes for setup, preoxygenation, and a team huddle. But sometimes, you have no such luxury. The patient is crashing, sats are plummeting, and the airway must be secured now. This is the crash airway—a situation every rookie dreads, but one that can be managed with clear principles and decisive action.

What Is a “Crash Airway”?

A crash airway exists when:

• The patient is apneic, pulseless, or peri-arrest, and delaying airway management to preoxygenate or prepare will cause death.
• There’s no time for the usual RSI steps; the airway must be taken immediately.

Examples:

• Cardiac arrest requiring intubation during CPR.
• Severe head trauma with GCS 3 and agonal respirations.
• Massive aspiration with ongoing desaturation despite BVM.

How It Differs from RSI

• RSI: Controlled, preoxygenation, induction + paralytic, carefully laid out Plan A/B/C.
• Crash Airway: No preoxygenation, no checklist, immediate intubation or airway insertion because the patient cannot survive delay.

Think: RSI is “controlled speed.” Crash airway is “act now, stabilize after.”

Management Principles

1. Prioritize Oxygenation Over Intubation

• If you can ventilate with a bag-valve-mask (BVM), do it. Sometimes all the patient needs immediately is effective BVM with adjuncts (OPA/NPA, two-person technique, PEEP).
• Don’t rush to intubate if bagging restores oxygenation—those extra seconds can buy you prep time.

2. Immediate Intubation if Bagging Fails

• If BVM is ineffective or the patient is in cardiac arrest, go directly for intubation.
• Use the most experienced operator available—first-pass success is critical here.
• If video laryngoscopy is present, use it (team can help troubleshoot in real time).

3. Skip the Drugs (Sometimes)

• In true crash airways, you may not give induction agents—because the patient is already deeply unresponsive or pulseless.
• Paralytics (e.g., rocuronium, succinylcholine) may still be useful to facilitate tube placement in agonal respirations or severe jaw clenching.
• But in cardiac arrest, it’s often “laryngoscope first.”

4. Backup Must Be Immediate

• If intubation fails: supraglottic airway (i-gel, LMA) goes in without hesitation.
• If oxygenation still fails: move to surgical airway (cricothyrotomy).
• There is no time for repeated attempts—desaturation is already critical.

5. Coordination With CPR

• During cardiac arrest, pause compressions briefly only for laryngoscopy attempt (≤10 seconds).
• If tube cannot be placed quickly, resume compressions and use SGA/BVM for ventilation.

Common Rookie Mistakes

• Fumbling with equipment—not knowing where the SGA or cric kit is kept.
• Too many laryngoscopy attempts—wasting 30–60 seconds while sats crash.
• Ignoring BVM—sometimes effective bagging is all that’s needed while preparing.
• Paralyzing unnecessarily—drugs delay action when the patient is already deeply comatose.
• Losing situational awareness—forgetting chest compressions in arrest or forgetting to confirm tube with EtCO₂.

Practical Crash Airway Workflow

1. Check responsiveness + pulse.
   • Arrest → compressions + airway immediately.
   • Agonal respirations/unresponsive → prepare to intubate.
2. Try bag-mask ventilation (with OPA/NPA, 2-person technique, PEEP).
   • If sats improve, gain a few seconds for prep.
3. If ineffective → intubate immediately.
   • Use VL if available, best operator, bougie ready.
4. If intubation fails → insert SGA instantly.
5. If oxygenation fails → move to surgical airway.
6. After tube in place → confirm with waveform capnography, then secure.

Rookie Pearls

• Always know where the SGA and cric kit are in your department.
• Even in a crash, shout out: “Plan A is tube, Plan B is SGA, Plan C is cric.”
• Never abandon EtCO₂ confirmation—tube in esophagus during a crash = wasted effort.
• Remember: oxygenation buys you time. Intubation does not, unless it restores oxygenation.

Take-Home Message

The crash airway is rare but terrifying. The rookie’s best defense is mental rehearsal and simplicity:

• Bag if you can, intubate if you must, cut if you can’t.
• Use your best operator and best tool first.
• Always have Plan B (SGA) and Plan C (cric) ready and visible.

In the ED, seconds count. The way to avoid panic in a crash airway is to practice the algorithm before it happens.