Airway management in the emergency department

C. A. Graham1, D. Beard2 and D. W. McKeown2

1 Glasgow UK 2 Edinburgh, UK

Editor—The debate on airway management in the emergency department continues unabated.15 One of the major difficulties surrounding this area is the definition of complications in this setting, and the lack of consistency in published studies which makes comparisons difficult and open to misinterpretation.

Berry2 misquoted from a preliminary abstract of the Scottish Rapid Sequence Intubation (RSI) study,6 by suggesting that 25% of RSI patients were intubated without an anaesthetic drug. The abstract actually states that 123 patients were intubated without the need for anaesthetic drugs and these were excluded from the reported group of patients that actually underwent a formal RSI. It may be of interest to note that this two year prospective study of nearly 1631 patients (of whom 735 had a rapid sequence intubation) is now complete and awaiting publication.7

The study shows that emergency physicians perform rapid sequence intubation on patients who are more physiologically unstable (91.8% vs 86.1%, P= 0.027), and on a higher proportion of patients within 15 min of arrival in the emergency department (32.6% vs 11.3%, P<0.0001) than do anaesthetists, with no statistically significant difference in complication rates (12.7% vs 8.7%, P=0.1). Anaesthetists achieve better laryngoscopic views (94.0% vs 89.3% P=0.039) and have higher first attempt success rates (91.8% vs 83.9% P=0.001), but the overall success rate is identical for the two specialties.7 8

Berry2 suggests that increasing the role of emergency physicians in airway management would ‘blur the boundary between the two departments’. We believe this would be of undoubted benefit to the critically ill patient by improving collaboration between the two specialties, along with training and standard setting in this critically important subject. The realistic suggestions for progress proposed by Nolan and Clancy1 9 are welcome and should be pursued in a careful and monitored fashion.

C. A. Graham1

D. Beard2

D. W. McKeown2

1Glasgow, UK

2Edinburgh, UK

References

1 Nolan J, Clancy M. Airway management in the emergency department. Br J Anaesth 2002; 88: 9–11[Free Full Text]

2 Berry J. Airway management in the emergency department. Br J Anaesth 2002; 88: 876–7[Free Full Text]

3 Davies G, Lockey D. Airway management in the emergency department. Br J Anaesth 2002; 88: 877

4 Kuehne J. Airway management in the emergency department. Br J Anaesth 2002; 88: 877–8

5 Adams M, Bandara L. Airway management in the emergency department. Br J Anaesth 2002; 88: 878[Medline]

6 Beale JP, Graham CA, Thakore SB, et al. Endotracheal intubation in the accident and emergency department. J Accid Emerg Med 2000; 17: 439

7 Graham CA, Beard D, Oglesby AJ, et al. Rapid sequence intubation in Scottish urban emergency departments. Emerg Med J 2002 (In press)

8 Graham CA, Beard D, Oglesby A, et al. Rapid sequence intubation in Scottish urban emergency departments. Emerg Med J 2002; 19: 279–80

9 Nolan J, Clancy M. Airway management in the emergency department. Br J Anaesth 2002; 88: 878–9[Medline]