A new chapter, developed from the previous Anaesthetic chapter in the previous Edition. Multi-professional considerations of the clinical situation where intubation of a woman is not possible or successful, and therefore further management and considerations are required as a team to ensure safety of the woman and her baby. Key learning points: Understand the indications for general anaesthesia in obstetrics. Be aware of the types of airways that may be used in a pregnant or postpartum woman. Understand why airway management may be more difficult in the obstetric setting. Know the key steps to prepare for a general anaesthetic in the pregnant or postpartum woman. Have a clear understanding of how to manage failed intubation. Be aware that, in the event of failed intubation, the team’s priority is the safety of the woman.

This case concerns a patient with a spontaneous nontraumatic intracranial hemorrhage while on anticoagulation. Learners will have to determine the cause of the patient’s altered mental status using clues from the history and physical, order the applicable imaging and laboratory testing, and initiate the appropriate management of this condition. In addition, the patient’s use of anticoagulants and declining mental status will test learners’ knowledge of anticoagulation reversal and airway management.

This chapter describes the case of a 56-year-old male brought in by EMS after cardiac arrest. The patient had a return of spontaneous circulation after pulseless ventricular tachycardia and was intubated and transported to the ED. The primary survey reveals a patent airway, no spontaneous breaths, and palpable radial and carotid pulses. The secondary survey shows an unresponsive patient with cool and pale skin. The diagnosis is pulseless ventricular tachycardia. The chapter highlights the importance of early identification, high-quality CPR, and defibrillation as mainstays of treatment for nonperfusing rhythms. Treatment options include targeted temperature management, antiarrhythmic drugs, and consultation with cardiology. The chapter also provides pearls for managing pulseless ventricular tachycardia, including the use of hypothermia and sedation to prevent shivering.

A severe earthquake has affected an area surrounded by oil refineries. During the initial response, an accident at a nearby location results in several patients becoming contaminated with oil. All patients are brought to the field hospital and require decontamination. Most patients are only mildly injured, but one suffers airway damage from oil and other hydrocarbons. The patient undergoes advanced airway management and is evacuated to a local hospital. The other patients are treated and released.

This scenario is based on the Whakaari/White Island volcanic eruption that occurred on December 9, 2019, in New Zealand. The eruption, classified as a Stage III burn disaster, overwhelmed local and regional medical systems, necessitating a national and international response. The scenario focuses on the initial receiving hospital’s experience and the on-shift medical staff’s challenges. It aims to provide a realistic training module for healthcare professionals in volcanic regions, emphasizing the importance of preparedness and skill practice. The scenario includes a fictional patient case with severe burns and other injuries, requiring comprehensive emergency care, including decontamination, airway management, fluid resuscitation, and wound care. The scenario also highlights the critical role of teamwork, communication, and resource management in handling mass casualty incidents. By reflecting on the Whakaari disaster, this scenario serves as a tribute to the victims, their families, and the responders, offering valuable insights for future emergency preparedness and response efforts.

The case features a 34-year-old male firefighter who suffers an asthma exacerbation due to inhaling volcanic ash while attempting to rescue civilians. Despite initially avoiding more severe physical injuries from pyroclastic flows or burns, he develops significant respiratory distress and requires escalating interventions, including nebulized bronchodilators and eventual intubation. Additionally, the patient presents with a head injury from debris, though imaging confirms there is no acute intracranial pathology. The case outlines key teaching objectives, emphasizing the recognition and management of inhalational injuries and asthma exacerbations, the challenges of managing a potentially difficult airway in the context of a volcanic eruption, and the specific medical interventions necessary for both respiratory support and trauma care. It also addresses the importance of effective communication and teamwork, such as the use of appropriate personal protective equipment (PPE) for responders, activation of disaster plans, use of local resources, and management of distressed family members.

This case outlines the management of a mass casualty incident (MCI) involving a 24-year-old male who sustained multiple stab wounds during an active shooter situation at a concert. The patient presents with significant injuries, including stab wounds to the back and upper extremities, hypotension, tachycardia, and respiratory distress. Upon arrival, the patient is intubated for airway protection, and procedures are performed to address tension pneumothorax and life-threatening bleeding. The case highlights key emergency principles, such as the importance of rapid trauma assessment, bleeding control, and chest tube placement. The article also discusses the challenges of managing critically ill patients in the context of an MCI, emphasizing the need for mass transfusion protocols, advanced imaging, and coordinated care with trauma surgery. This scenario serves as a training tool for preparing emergency medical teams to handle multiple traumatic injuries under the pressure of an MCI.

This scenario presents a 54-year-old woman with a history of hypertension who is brought to a rural critical access emergency department after being shot during an active shooter incident at a grocery store. She has multiple penetrating wounds to her neck, groin, and extremities, requiring immediate hemorrhage control, resuscitation, and airway management. The patient is initially hypotensive, tachycardic, and in hemorrhagic shock. Lifesaving interventions such as wound packing, tourniquet application, IV or IO access, and blood transfusions are crucial to stabilize her condition. As her condition worsens, an expanding neck hematoma necessitates securing the airway, with a potential need for a surgical airway. The scenario emphasizes the need for prompt recognition of life-threatening injuries, coordination of care for transfer to a trauma center, and the preparation of the emergency department for the arrival of additional victims from the scene, highlighting key principles in trauma management and disaster preparedness.

This scenario presents a detailed simulation of a chlorine gas exposure incident following a freight train derailment. The scenario begins with a standardized patient and transitions to a manikin, set in a community hospital in the United States. The patient, a 47-year-old male freight engineer, was exposed to chlorine gas after a train derailment caused by a track defect. The simulation covers the initial emergency response, patient decontamination, and subsequent medical management, including the challenges of airway stabilization and treatment of acute respiratory distress syndrome (ARDS). Key teaching objectives include identifying hazardous materials, diagnosing and managing chlorine exposure, and effective teamwork and communication during a medical crisis. The scenario emphasizes the importance of rapid identification and treatment of chemical exposures and provides a comprehensive guide for healthcare professionals in managing similar emergencies.

This case presents a scenario involving a 45-year-old postal worker with inhalational anthrax following a suspected bioterrorism attack. The patient arrives at the emergency department in critical condition, presenting with shortness of breath, altered mental status, and a widened mediastinum on chest X-ray. His wife reports flulike symptoms over the past few days, and both she and the patient work in a mailroom at a government office. The scenario focuses on recognizing and managing inhalational anthrax, a rare but life-threatening condition. Key teaching points include securing the airway, fluid resuscitation for septic shock, and appropriate antibiotic therapy. Additionally, it emphasizes the importance of notifying public health and law enforcement authorities to manage the potential bioterrorism threat. The case highlights the critical need for timely intervention, proper use of personal protective equipment, and coordination with infection control and public health authorities during a bioterrorism event.

This case focuses on the response to traumatic asphyxiation following a stampede at a county fair, leading to the compression of a 26-year-old female against a wall. The scenario highlights the need for rapid trauma assessment in a resource-limited rural hospital with limited critical care capacity. The patient presents with respiratory distress, diminished lung sounds, bruising, and petechiae, consistent with traumatic asphyxiation. Key interventions include airway management, intubation, placement of chest tubes, and initiation of blood transfusion to manage her respiratory and hemodynamic status. The patient also shows signs of a hemothorax, necessitating emergency interventions and stabilization before transfer to a trauma center. The case emphasizes early recognition of traumatic asphyxiation, resource management, and coordination with higher levels of care, while also addressing the complexities of triaging additional patients from a mass casualty event.

An anaesthetist may control the airway through the application of several methods and the use of specific equipment. Primarily, the patient’s position must be optimised to allow for an open airway. An appropriate face mask should be fitted around the patient’s mouth ensuring there are no leaks. In the case of an obstructed upper airway the use of oral or nasal devices, such as a Guedel or nasopharyngeal airway, can allow the obstruction to be bypassed and aid effective oxygenation. Supraglottic airway devices (SADs), such as the laryngeal mask or i-gel, are frequently used to provide oxygenation and ventilation in spontaneously breathing patients and form part of the difficult airway algorithm. A variety of devices and generations are now available which have additional benefits of allowing gastric content suction and the passage of flexible scopes to visualise the airway and aid intubation. The tracheal tube is discussed with all its features and benefits of allowing for a definite and secure airway.

Both anaesthesia for maxillofacial and ENT surgery may require ‘sharing’ the airway with the surgeon, or at least having limited access to the airway and a number of airway devices are available to ensure the patient has a patent and secure airway at all times.

A number of areas need to be considered. Many patients are children, there is a risk of airway contamination with blood, bone teeth etc. In particular, perioperatively, it is easy to underestimate blood loss blood can be swallowed. Another area is patients with head and neck cancers. These patients may not only have a number of comorbidities (heavy alcohol and/or nicotine use, cachexia and weight loss) but have very difficult airways to manage because of tumour involvement or radiotherapy.

Patients with significant airway problems (from infection, tumour, radiotherapy) may need awake fibreoptic tracheal intubation)

Middle ear surgery may also require induced hypotension and prophylaxis of postoperative nausea and vomiting.

Tracheal intubation is a fundamental skill in airway management and there are several techniques used to achieve this. Classically, the use of a laryngoscope has been used for intubation of the airway by allowing direct visualisation of the glottis. A range of laryngoscopes exist with differences in their blades and sizes with the Macintosh blade the most frequently used. Other laryngoscopes discussed include the Miller and McCoy. Videolaryngoscopes consist of a high-resolution camera at the tip of the blade to allow for indirect visualisation of the glottis. Similarly, the range of shapes and sizes is vast. The use of videolaryngoscopes has introduced the ‘shared screen’ principle allowing others to also have a view during intubation and this can aid training and teaching. Awake tracheal intubation can be performed using flexible scopes or videolaryngoscopes and is recommended for anticipated difficult airway cases. Confirmation of tracheal tube placement is critical and should be performed in every case using capnography. Clinical signs may be unreliable and additional uses of flexible scopes and ultrasound may also be used.

This chapter is written for practitioners working within the perioperative environment that require an understanding of how to assess and manage a patient’s airway. An introduction to airway anatomy highlights relevant anatomical landmarks, and a number of techniques that can be employed for both basic and advanced airway management are described. Airway equipment used by the anaesthetic practitioner will vary depending on requirements of the patient and procedure. Therefore, an overview of both standard and specialist airway equipment available, and how this is used to establish and maintain a patent airway, is provided.