Airway management in emergency department thoracotomy: A narrative review

INTRODUCTION: Emergency department thoracotomy (EDT) is a high-risk, life-saving intervention for patients in traumatic cardiac arrest. A critical component of EDT is airway management, typically performed by emergency physicians, yet formal guidance regarding optimal strategies remains limited. Airway management in this setting is uniquely complex due to concurrent anatomic injury, physiologic instability, and the procedural demands of thoracotomy. DISCUSSION: Endotracheal intubation (ETI) during EDT presents multiple challenges. Anatomic difficulties may arise from facial or cervical trauma, restricted positioning, and the presence of cervical collars. Cognitive load is heightened by the chaotic, multidisciplinary environment, requiring strategies such as pre-briefing, checklists, and closed-loop communication. To optimize outcomes, the most experienced operator should perform ETI, preferably using video laryngoscopy, which improves visualization and confirmation of tube placement. Adjunctive measures to facilitate procedural success include preparation for airway contamination, selective mainstem intubation to facilitate surgical exposure, and orogastric tube placement to aid intra-thoracic orientation. While supraglottic devices or surgical airways may serve as temporizing options, definitive endotracheal access remains the standard. Ventilation management must be closely coordinated with the thoracotomy team, with adjustments for single-lung ventilation, reduced tidal volumes, and decompression as indicated. CONCLUSIONS: Airway management during EDT requires technical expertise, adaptability, and seamless communication between emergency physicians and surgical teams. Video laryngoscopy, selective ventilation strategies, and early orogastric tube placement can optimize procedural success. Protocolized, team-based approaches are essential to overcoming the unique airway challenges of EDT.