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A patient may require intubation while positioned upright, for example, when trapped in a car. One described approach is to perform intubation while directly facing the patient. With this technique, the operator holds the laryngoscope with the right hand, inserting the laryngoscope blade in an inverted fashion (“tomahawk” or “ice axe” approach) and passing the tracheal tube with the left hand (Figure 4.6).

Figure 4.3 Kneeling intubation.

Figure 4.4 Sitting intubation.

A study using mannequins in a model of a victim trapped in a motor vehicle compared face‐to‐face intubation with five types of video laryngoscopes and traditional Macintosh laryngoscopy [5]. Interestingly, the fastest time to intubation was with traditional Macintosh laryngoscopy, although the video laryngoscopes provided a better view of the glottis. Of the five video laryngoscopes studied, the two with integrated tube guides were associated with shorter times to intubation. Numerous studies have compared various video laryngoscopes, providing insight to their relative strengths and validating their appropriateness for in‐field deployment [6, 7].

Figure 4.5 Straddle intubation.

Figure 4.6 Face‐to‐face “tomahawk” intubation position.

When face‐to‐face intubation is the only available option, the EMS clinician should evaluate whether immediate airway intervention or patient extrication is most appropriate. The estimated time of extraction combined with patient condition may influence the decision‐making process. High‐flow oxygen devices and supraglottic airways may provide suitable alternatives in these situations.