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Emergency Department Management of Surgical Airway Complications -

Emergency Department Management of Surgical Airway Complications
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Publication Date: November 2022 (Volume 24, Number 11)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 11/01/2025.


John Dubensky, DO
Resident Physician, Einstein Medical Center, Philadelphia, PA
Chelsea Schmidt, DO
Resident Physician, Einstein Medical Center, Philadelphia, PA
Scott Goldstein, DO, FACEP, FAEMS, EMT-PHP
Director, Division of EMS/Disaster Medicine; Director, Division of Tactical Medicine, Einstein Medical Center, Philadelphia, PA

Peer Reviewers

Calvin A. Brown, III, MD
Associate Professor of Emergency Medicine, Harvard Medical School, Boston, MA
Michael Self, MD
Fellow, Emergency Medicine and Anesthesia Critical Care Medicine, University of California San Diego Health, San Diego, CA


Emergency clinicians are often responsible for the acute management of complications pertaining to both the acute difficult airway and the chronic surgical airway; however, clinical knowledge and/or experience may be lacking. This review provides an overview of surgical airway complications, which can be a result of mechanical, infectious, or hematologic causes, and provides best-practice recommendations. Current consensus guidelines for the management of the difficult airway and indications for a surgical airway are discussed.

Case Presentations

EMS brings in a 54-year-old man who has a swollen tongue and is in obvious respiratory distress…
  • He is tripoding with accessory muscle use, demonstrates conversational dyspnea, and is drooling. His vital signs are significant for hypoxemia that corrects with a nonrebreather mask, tachycardia, and hypertension.
  • You see on his medication list that he takes lisinopril, and you are concerned he has progressing angioedema, so you decide to intubate.
  • Using an awake, flexible video laryngoscopic approach, you visualize swelling extending beyond the base of his tongue, and you are unable to pass the endotracheal tube.
  • The patient’s swelling is getting worse, and he is now becoming hypoxic.
  • How will you secure a definitive airway on this patient?
A 48-year-old man with a history of prolonged ICU stay for pneumonia who is status post tracheostomy presents to the ED after his tracheostomy tube fell out at home…
  • He is in no respiratory distress upon presentation, and he is not ventilator-dependent.
  • The patient’s family did not bring the tube that fell out, and they are unable to recall the size of his tracheostomy tube. They inform you that his surgery was approximately 6 months ago.
  • Upon your inspection, the skin surrounding the tracheostomy site appears well-healed, without evidence of bleeding or soft-tissue infection.
  • The patient’s surgery was not performed at your hospital, and you are unable to access outside records.
  • What is the best course of action to manage this patient’s dislodged tracheostomy tube?
A 41-year-old woman with a history of cerebral palsy presents to the ED from her long-term care facility for hypoxemia, with pulse oximetry measured at 84%…
  • She is status post tracheostomy, with a percutaneous endoscopic gastrostomy (PEG).
  • The patient is ventilator-dependent, and when the respiratory therapist takes her off the travel ventilator and attaches her to your ventilator, the ventilator alarm sounds for increased pressures.
  • The patient’s nurse reports increased secretions from the tube, requiring frequent suctioning. Your examination shows crusted mucus inside the inner cannula, with clear secretions.
  • What is the best way to clear obstructive secretions from the tracheostomy tube?
A 26-year-old woman presents from her brain injury rehabilitation facility for bleeding from her tracheostomy site…
  • The patient has a history of prolonged surgical ICU stay after multiple gunshot wounds. She is status post tracheostomy, with a PEG. Her tracheostomy was placed approximately 1 month ago, and blood appears to be oozing from the site.
  • The patient’s vital signs are within normal limits, and she appears well, apart from the bleed.
  • Are there red flags in this patient’s presentation?


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