If you were faced with a stab wound to the neck and had to act fast, would you have a well-thought out plan that you are comfortable with? In this EM Cases Best Case Ever podcast we discuss the do’s and don’ts of penetrating upper airway injury awake intubation with airway expert George Kovacs….

Podcast production, sound design and editing by Rajiv Thavanathan, Richard Hoang & Anton Helman

Blogpost by Anton Helman September, 2017

Do’s in Penetrating Upper Airway Injury Awake Intubation

Do some deep breathing and self talk +/- visualization/deliberate mental rehearsal before managing the dangerous airway.

For awake intubation, do explain to the patient what you are doing. You need their co-operation to to maximize your chances of success. If you can’t get their co-operation consider ketamine.

Do have a triple set up ready. Video laryngoscope set to get a view of the vocal cords and ask assistant to hold it, then add flexible intubating scope; plus set up for cricothyrotomy as a default.

Do use an atomizer to administer 4% lidocaine such as EZ Spray (see video below) rather than a nebulizer.

Awake Intubation

Georg Kovacs performing an awake intubation in a patient with a penetrating injury to the upper airway

Dr. Kovacs reviews awake intubation in the case of an obstructed airway on this CritCases 

Don’ts in Penetrating Upper Airway Injury Awake Intubation

Don’t wait to intubate a patient with a potential penetrating upper airway injury. The neck is a closed space. If you suspect that the patient with a penetrating neck injury has an airway that is obstructed, distorted or disrupted, they’re good until they’re dead. In other words, deterioration will be rapid and a panic situation will ensue.

Don’t choose RSI only because that’s what you’re most comfortable with. There are some situations where awake intubation, which most of us are not as familiar with, is preferred. If you aren’t’ familiar with awake intubation, practice with simulation.

If you do an RSI, don’t do anything blind because you can disrupt the upper airway further.

Don’t use positive pressure ventilation (no bagging, no supraglottic device) to avoid worsening subcutaneous emphysema.


Sowers N, Kovacs G. Use of a Flexible Intubating Scope in Combination with a Channeled Video Laryngoscope for Managing a Difficult Airway in the Emergency Department. J Emerg Med. 2016;50(2):315-9. Full pdf

Dr. Kovacs’ masterclass talk at ResusTO on Awake Intubation

Other FOAMed Resources on Penetrating Upper Airway Injury and Awake Intubation

Dr. Kovacs reviews awake intubation in the case of an obstructed airway on this CritCases