A 33-year-old woman is brought to the emergency room from the scene of a severe motor vehicle accident. She is combative, confused, uncooperative, and appears dusky and dyspneic. Which of the following is the most appropriate management of her airway?

Securing a stable airway is one of the most fundamental and impoant aspects of the management of the severely injured patient. The level of control required will vary from a simple oropharyngeal airway to tracheostomy, depending on the clinical situation. Full control of the airway should be secured in the emergency room if the patient is unstable. Endotracheal intubation will usually be the method chosen, but the physician should be prepared to do a tracheotomy if attempts at perioral or perinasal intubation are failing or are impractical because of maxillofacial injuries. The most dangerous period is just prior to and during the initial attempts to get control of the airway. Manipulation of the oronasopharynx may provoke combative behavior or vomiting in a patient already confused by drugs, alcohol, hypoxia, or cerebral trauma. The risk of aspiration is high during these initial attempts, and the physician should make no assumptions about the state of the contents of the patient's stomach. Antacids are recommended just prior to the intubation attempt, if feasible. Although steroids have been recommended in the past, they are no longer considered of value in the management of aspiration of acidic gastric juice. The best management requires prevention of the complication of aspiration. In a reasonably cooperative patient, awake intubation with topical anesthesia may help to prevent some of the risks of hypotension, arrhythmia, and aspiration associated with the induction of anesthesia. If awake intubation is inappropriate, then an alternative is rapid-sequence induction with a thiobarbiturate followed by muscle paralysis with succinylcholine. If elevated intracranial pressure is suspected, or if a penetrating eye injury exists, awake intubation is contraindicated.