41.1 The traumatised and difficult airway presents one of the most challenging emergency clinical situations. This challenge increases significantly in the relatively isolated and resource-depleted pre-hospital and retrieval environments. The critical decision required is whether the PHR team should establish a definitive airway before departure or support the airway and observe the patient en route to a definitive facility. When making this decision, there are a number of factors to consider. Some of these are outlined below and can be considered in terms of patient factors, team factors, transport platform factors as well as assistance and advice.