• The incidence of penetrating neck trauma is reported to be approximately 1–5% of all traumatic injuries. Innocuous-appearing neck injuries have the potential to cause either immediate or delayed life-threatening injuries and complications. Penetrating neck injuries are generally described according to the zones of the neck. This helps to define the potentially injured structures and allows for a common nomenclature.

Airway management is one of the core fundamental skills of the emergency medicine and critical care physician. Airway management is time-critical and can literally mean the difference between life and death. Airway management encompasses the overlapping management of oxygenation, ventilation and airway protection.

This chapter explains the fundamental elements of resuscitation. Patients in cardiorespiratory arrest require prompt and effective resuscitation to improve chances of a good outcome. Identification of the underlying cardiac rhythm and treatment of any reversible causes is critical to achieve patient survival. A structured ABCDE approach and the ALS algorithm are commonly adopted to optimise patient assessment and management. An awareness of both technical and non-technical skills are important when dealing with the acutely deteriorating patient.

This chapter focuses on the perioperative care of the paediatric patient and aims to undermine the common misconception that children are just little adults. Providing safe and effective care for children requires a clear underpinning knowledge of their unique needs. Conscious consideration of age-dependent characteristics such as anatomical, physiological, psychological, and behavioural are essential in the delivery of paediatric patient care. The rationale for adaptations to the delivery of care is to ensure children receive anaesthesia and surgery in a safe and appropriate environment.

Anaesthetic breathing systems are used to deliver oxygen and anaesthetic gases to patients and remove carbon dioxide. A breathing system is most commonly attached to an anaesthetic machine, which is designed to deliver the fresh gas flow to the patient via a facemask, a supraglottic device or an endotracheal tube. The breathing system used can affect the composition of the gas and volatile anaesthetic mixture inhaled by the patient, and so it is important to understand the different breathing systems used in anaesthesia. This chapter describes the key components of the different breathing systems and explores the benefits and disadvantages of the circuits in the Mapleson classification.

Advanced imaging of the mid-gestation fetus has allowed for the early detection and monitoring of conditions that may impact the delivery of the baby. Large head and neck masses that will likely compromise ventilation at birth can therefore be easily diagnosed with plans for securing the airway at birth. Ex-utero intrapartum therapy has greatly enhanced survival for such affected infants at birth. The success of this approach in providing advanced airway management at delivery has also been extended to the treatment of other conditions that may be life-threatening within the first few minutes to hours of life.

Oxygenation is the primary aim of all airway management. The shape of the oxyhaemoglobin dissociation curve determines onset of hypoxaemia and means that when it occurs it can progress rapidly and severely. Hypoxaemia causes rapid damage to living tissues, most importantly the brain. Oxygenation strategies are required including delivering oxygen before, during and after airway management. Low flow oxygenation techniques are traditionally employed and apnoeic oxygenation has been rarely used. Newer high flow oxygen delivery systems enable effective pre-oxygenation and apnoeic oxygenation and can be used both during complex airway management or as an alternative to instrumenting the airway during surgery.

The virus responsible for the coronavirus-19 pandemic is predominantly spread by droplet and contact routes of transmission. Many airway management interventions, particularly when applying positive pressure to the airway, generate aerosol particles which pose a further risk of airborne viral transmission. The fundamental principles of airway management in the setting of a respiratory epidemic are not changed but it is essential to maximise safety for both the patient and all staff involved in caring for them. The airway manager should fully understand and apply principles of infection prevention and control, including understanding and matching personal protective equipment (PPE) to the prevailing mode of viral transmission. Airway management should be meticulously planned, safe for the patient and staff, be undertaken by skilled operators using reliable, well-practised techniques and should aim to achieve high first-attempt success rates so that securing the airway is timely and swift.

Correct choice and use of drugs is fundamental to airway management success and safety. This is true for both elective and emergency anaesthesia and at the start and end of anaesthesia. This chapter describes the key elements of drug selection for safe, effective airway management in both the awake and anaesthetised patient. Drugs can importantly facilitate airway management and influence conditions for tracheal intubation or inserting a supraglottic airway. Depression of reflexes and muscle tone can be provided by several hypnotics, but propofol is usually most effective. Neuromuscular blocking agents are not needed for many forms of airway management but can optimise conditions when necessary. The anaesthetist must be familiar with dosing and timing and with quantitative monitoring during reversal. Local anaesthesia may be the only safe choice in managing the difficult airway and sedation can enhance patient tolerance but maintaining adequate spontaneous ventilation is sometimes a challenge.

Tracheal tube introducers or bougies and airway exchange catheters (AECs) are widely used airway adjuncts for facilitating airway management in difficult circumstances. They are easy to use, relatively inexpensive and have success rates of ≥ 90% in most settings. Both are included in many modern airway management algorithms. The use of bougies has expanded over the years, and they are now used to aid insertion of supraglottic airways (SGAs), videolaryngoscope-guided intubation and as adjuncts to emergency front of neck airway procedures. Stylets are rigid or semi-rigid airway adjuncts that are inserted into the tracheal tube before intubation. They maintain the tracheal tube in a particular shape and may therefore assist during intubation. AECs are semi-rigid hollow tubes designed to aid airway device (SGA, and single- or double-lumen tracheal tube) exchange or to manage ‘at-risk’ extubation. The risk of serious airway trauma associated with the use of bougies and airway exchange catheters, and the risk of barotrauma with the latter, invites cautious and educated use of these devices.

This chapter explores the well-established skill of upper airway endoscopy as a tool for assessing the upper airway and planning the best airway management approach for anaesthesia. It also describes the emerging modality of virtual airway endoscopy, which can examine both upper and lower airway, and its potential roles. Both techniques focus on examination of the air column within the airway (Greenland’s ‘middle column’) but can reach beyond the sight of the naked eye. Both techniques have potential to aid understanding of the patient’s airway anatomy and pathology and can enable improved airway planning.

Supraglottic airways (SGAs) have been part of core anaesthetic practice for approximately 30 years, since the introduction of the classic laryngeal mask which is described in some detail. In many countries an SGA is now used for airway management for the majority of anaesthetics. Optimal use and insertion technique are described. The range of SGAs available and their roles have expanded dramatically in this time. Second generation SGAs are those designed to reduce the risk of aspiration and are emphasised in this chapter. With the wide range of SGAs available it can be problematic to decide which device to use and this is especially so as the boundaries of acceptable use are ever widened. This chapter describes those devices with the greatest versatility and utility – arguably also with the greatest safety profile too – and some newer devices. SGAs have a major role to play in advanced and difficult airway management. The use of an SGA as a rescue device and as a conduit for intubation during management of the difficult airway is described in detail.

Ultrasonography is an established modality in medical imaging and is evermore entering clinical practice. This chapter provides an introduction to the principles of clinical ultrasonography. It describes the use of airway ultrasonography for identification of the cricothyroid membrane, the trachea and for confirming correct tracheal intubation. Bedside ultrasonography by the anaesthetist has a much higher success rate than palpation for identifying the cricothyroid membrane, especially in patients with neck pathology. It should be applied before initiation of airway management and not be delayed until airway problems are apparent. The role of lung ultrasonography for identification of normal ventilation and pathology is described. Gastric ultrasonography for assessing the starvation status of a patient is described.