title: The difficult airway in the emergency department.
abstract: BACKGROUND
  The patient with difficult airways is a common challenge for emergency physicians.
  
  
  OBJECTIVE
  Our goal was to study the reasons for difficult airways in the emergency department.
  
  
  METHODS
  We performed a prospective observational study of patients requiring advanced airway management from 1 January 2000 to 31 December 2006.
  
  
  RESULTS
  There were 2,343 patients who received advanced airway management of which 93 (4.0%) were deemed difficult. The main diagnoses were cardiac arrest (28), trauma (27) and congestive heart failure (10). The main reasons for the difficult airways were attributed to an anterior larynx (38, 40.9%), neck immobility (22, 23.7%) as well as the presence of secretions and blood (14, 15.1%). The mean number of attempts at intubation was 3.6 versus 1.2 for all cases. The mortality rate of 40.5% among patients with difficult airways was not different from that of all patients who had airway management (41%). There were seven (0.3%) failed airways. Anaesthetists performed 21 (22.6%) of the rescue airways while surgeons performed 5 (5.4%). Of the rescue strategies performed, 24 were through the use of the bougie, 3 by cricothyroidotomy, 4 by tracheostomy, 6 with the GlideScope and 3 with the laryngeal mask airway. The rest the airways were secured by tracheal intubation using the laryngoscope.
  
  
  CONCLUSIONS
  Emergency physicians manage most of the difficult airways successfully (68.8%). However, the success rate can be further improved through the more frequent use of the bougie or other rescue device. A possible suggestion would be for the emergency physician to use the bougie after the second or third attempt at direct orotracheal intubation.
authors.affiliation: Department of Emergency Medicine, Singapore General Hospital, Singapore. evelyn.wong@sgh.com.sg
authors.forename: Evelyn
authors.initials: E
authors.lastname: Wong
authors.forename: Yih-Yng
authors.initials: YY
authors.lastname: Ng