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Airway Management: Medicolegal Pitfalls

Glauser, Jonathan MD, MBA

Legal Notes

A 4-month-old infant has reactive airway disease, and is in extremis. She is being airlifted from a rural hospital to a regional children's hospital when she sustains a respiratory arrest. There is a physician staffing the helicopter. He successfully intubates her with the most appropriately sized tube available, which is a 4.5 mm ET tube. She is resuscitated successfully, and ends up with no neurologic deficit. She is extubated three days later.

Although she has normal development, she has prolonged problems with her voice and with airway obstruction stemming from subglottic stenosis. This requires multiple procedures and hospitalizations during her early childhood, including tracheostomy. A lawsuit is brought against the emergency physician staffing the helicopter some years later for using such a large endotracheal tube. The child cuts a very sympathetic figure in court as a lively and vivacious 6-year-old whose parents wish she could have sung like other children in the first grade.

A 17-year-old asthmatic is brought to a hospital in Massachusetts. She is in severe distress and quite agitated. The physicians in the emergency department restrain her, and after much wailing and gnashing of teeth, successfully intubate her. She not only lives, but walks out of the hospital with no untoward sequelae. One year later, she has another episode of status asthmaticus. This time she refuses to be transported to the hospital at all, as her experience in the ED one year before is etched in her mind as so traumatic she cannot stand the thought of seeking care there. She dies at home. The family brings suit against the emergency physicians who treated her the year before.

An 11-year-old is riding his recently purchased dirt bike. It is twilight when he is trespassing on the property of the electric company. His neck hits a guidewire, and he is thrown from the bike. The rescue squad notes he is in extremis, and take him to the nearest hospital, which is not a trauma center. He is gasping for air and cyanotic on arrival. EMS has administered oxygen by mask during transport, and the run sheet lists him as “improved” on arrival to the ED. The doctor in the ED pages overhead for any physician still in the hospital to hurry to the ED.

He places an endotracheal tube through the vocal cords, and the patient arrests. He and an orthopedic surgeon who was on his way home perform a surgical airway only to find to their horror that the ET tube and the inflated balloon is subcutaneous, having passed through a transected trachea. By the time they fish the stump of his proximal trachea out of his mediastinum, the patient has been in cardiac arrest for 10 minutes. He is pronounced the next day, having had a cardiac rhythm re-established after 30 minutes.

In court, an expert otolaryngologist testifies that a surgical airway should have been placed initially, that the intubation severed what tenuous airway the child had, causing the child to die. Besides the hospital and the resuscitating physicians, the electric power company is sued as well. In fact, the rescue squad is mentioned for not taking the patient to a trauma center, roughly 10 minutes further.

Dr. Glauser is an assistant professor of medicine at Case Western Reserve University and attending staff faculty in emergency medicine at the Cleveland Clinic Foundation in Cleveland.

Airway management is a basic skill that entails more than simple intubation: Use technology to your advantage

As we are all taught, A is for airway. Nothing trumps it. Nothing precedes it in a code, and any emergency physician who is not well versed in its management practices at his peril and the peril of patients. Yet, it is not frequently discussed at risk management conferences, although supraglottitis and laryngotracheobronchitis are frequent topics of discussion.

Airway management frequently entails anesthesia, the ENT service, and an operating room with availability of an open tracheostomy and rigid bronchoscopy.1 These recommendations are fine to discuss at a CME conference in the Marriott but of limited value to the doctor transporting the child in the first case nor, I suspect, for the majority of physicians practicing in community hospitals without immediate access to these resources 24/7. All of these cases are true.

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Traumatic Complications

Injury frequently occurs without initial difficulty managing the airway. In one report, six percent of closed claims against anesthesiologists were for airway trauma during anesthesia.2 These may be as benign as upper lip contusions or injuries to the temporomandibular joint or the uvula. Dental injury historically occurred in between one of every 150 to 1000 intubations3 More recent data show dental injury to occur in one of every 4500 cases.4 Traumatic perforation of the esophagus with mediastinitis was fatal in nine of 19 cases in one closed claims analysis.2

EPs do not have an option of canceling a case because of airway difficulties, real or anticipated

As in the first case, laryngeal injury and tracheal injury may include vocal cord paralysis, granuloma formation, arytenoids cartilage damage, tracheal laceration, and subglottic edema and stenosis.5

The case would have gone more favorably if a proper endotracheal tube size had been selected in the first place. Interestingly, the pediatric hospital which managed the girl during her initial hospitalization left the “oversized” ET tube in for the first three days of her hospitalization, and were not named in the suit.

Recall also that emergency physicians in many hospitals seldom hear of complications down the road. Pharyngeal and esophageal perforation may later present as subcutaneous emphysema, pneumonia, retropharyngeal abscess, or mediastinitis. Emergency intubation in and of itself is a risk factor for claims related to airway injury.6

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Standard of Care

Who should determine standard of care for airway management? Anyone who has read this column before must know the answer to this leading question. Anesthesiologists and otolaryngologists are airway experts but in a different and not always relevant way to the practice of emergency medicine.

Recall that rapid sequence intubation (RSI) by definition entails nearly simultaneous administration of a neuromuscular blocking agent and a potent sedative agent to facilitate endotracheal intubation without using bag-valve ventilation. Specifically, the patient isn't prepped in any way. We don't have options to decline an operative procedure. We have to secure an airway even if the patient is obese, has cervical arthritis, or has a possible cervical injury. We can't sit them up to get an accurate Malampati score.

Injury frequently occurs without difficulty, but 6% of claims against anesthesiologists were for airway trauma during anesthesia

In fact, a look at RSI assumptions gives an idea of what the EP is up against when confronted with an agitated 270-pound muscular 22-year-old who just crashed his Harley at 2:30 a.m.:

  • ▪ Patient has a full stomach, making bag-valve-mask (BVM) undesirable.
  • ▪ If the patient's underlying condition (morbid obesity, lung disease, primary hypoventilation) does not allow adequate pre-oxygenation, then bag-valve-mask may be necessary prior to laryngoscopy.
  • ▪ Some form of definitive airway can and must be secured, even if attempts at intubation are unsuccessful: The caregiver must be proficient at bagging, and ready for surgical airway management (?1–2%).
  • ▪ RSI can be used to prevent the aspiration of gastric contents in the critically ill patient.
  • ▪ C-spine movement must be minimized.
  • ▪ Intracranial pressure spikes must be minimized.
  • ▪ Hypotension must be minimized.
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Early Rules

It is difficult to define what the first rule in airway management would be, but a couple of early rules would be:

  • ▪ Never paralyze a patient who is awake and able to remember!
  • ▪ People should not remember their own intubation. (Some exceptions here: We all know patients who will tell us they need intubation.)

Of course, no rule in the world applies 100 percent of the time, especially in the emergency department. Awake oral intubation has been considered if the patient has a condition that will make intubation and BVM difficult, such as blunt or penetrating neck trauma. But it does require a highly cooperative patient. Furthermore, there would still be a role for nebulized xylocaine/0.5% neosynephrine for five to 10 minutes, with some sedation of dissociative agent.

The court was not sympathetic toward the physicians sued in the case of the 17-year-old asthmatic, even though there was no direct involvement in her care the day of her death or in the year preceding her death. The concept of proximate cause obviously can go a long way. The number of anxiolytics, narcotics, induction agents, and dissociative agents we have at our disposal is too great to expect a court to be sympathetic to a physician who did not sedate a patient for intubation.

The court found for all of the defendants in the third case. I personally have never run into a person when queried who thought they could have saved this boy's life except for that ENT expert who thought that a “little curare” would have sufficed to enable him to do a rapid tracheotomy. It is unfortunate that the rescue squad listed the child's condition as “improved” after oxygen administration. The plaintiff's lawyer almost had a field day with that one because a live and “improved” healthy 11-year-old left the hospital dead.

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Learning from Anesthesiology

Anesthesiology is probably the only medical discipline that has shown a concerted effort to address error in medicine. Deaths due to anesthesia were 1:10,000 a few decades ago, and stand at approximately 1:250,000 currently. An example would be esophageal intubation. There are many methods for confirming intubation, none of which is as good as seeing the tube go through the vocal cords:

  • ▪ End-tidal CO2 detection: May give false negatives in severe bronchospasm, cardiac arrest, plugging or kinking of the ET tube; may give false positives as well.
  • ▪ Symmetric breath sounds.
  • ▪ Tube misting.
  • ▪ Chest rise and fall.
  • ▪ Pulse oximetry, although desaturation may take 10 minutes to occur in the fully pre-oxygenated patient.

Suffice it to say that capnography and pulse oximetry must be available and used. Equipment such as pulse oximeters can fail; scalding water may spill into the patient breathing circuit of a heated humidifier; PCA pumps may be inadvertently programmed to administer extremely high narcotic doses, and so forth. Most airway problems in the ED involve human error, however: unrecognized esophageal intubation, giving drugs before checking equipment, or breaking a tooth while intubating.

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Bottom Lines

Airway management is a basic skill, and entails more than simple intubation. Rapid sequence intubation mandates being familiar with a variety of sedative as well as at least one or two paralytic agents. It is barbaric for patients to remember their own intubation.

Anesthesiologists are airway experts, but in a different way from emergency physicians. EPs also may have patients who have been NPO after midnight if they present at 12:07 a.m. It is a sure thing that they have recently ingested pasta and at least 10 beers. We do not have an option of canceling a case because of airway difficulties, real or anticipated.

Give some credit to those who care for critically ill patients after we send them to intensive care. EPs often do not hear about nerve injuries, mediastinitis, and retropharyngeal abscesses following successful resuscitations. These do not, of course, necessarily represent breaches in standard of care on our part.

Bad things happen to critically ill patients who crash in the ED. Nonetheless, there are standards with which every EP should be familiar. Besides the ability to sedate and paralyze patients, it is appropriate to know age-appropriate equipment. Use technology to your advantage.

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1. Vener D, Lerman J. The pediatric airway and associated syndromes. Anesth Clin North Am 1995;13:585.
    2. Domino KB. Closed malpractice claims for airway trauma during anesthesia. Am Soc Anesthesiologists Newsletter 1999;91(6):1703.
      3. Lockhart PB, et al. Dental complications during and after tracheal intubation. J Am Dent Assoc 1986;112:480.
      4. Warner ME, Benenfeld SM, et al. Perianesthetic dental injuries: frequency, outcomes, and risk factors. Anesthesiology 1999;90:1302.
      5. Weber S. Traumatic complications of airway management. Anesth Clin N Am 2002;20(3):503.
        6. Tartell PB, Hoover LA, et al. Pharyngoesophageal injuries. Am J Otolaryngol 1990;11:256.
        7. Cooper JB, Newcomer RS, Ritz RJ. An analysis of major errors and equipment failures in anesthesia management: Considerations for prevention and detection. Anesthesiology 1984;60(1):34.
        © 2003 Lippincott Williams & Wilkins, Inc.