Airway integrity, assurance of oxygenation, ventilation, and
prevention of aspiration are the mainstays of emergency airway management.
The indications for tracheal intubation in the ED include correction
of hypoxia or hypercarbia, prevention of impending hypoventilation,
and ensuring maintenance of a patent airway. Secondary indications
include provision of a route for resuscitative medication administration
and to permit temporizing paralysis during diagnostic testing.
Rapid-sequence intubation (RSI) is the simultaneous administration
of an induction agent and neuromuscular blocking agent to facilitate
endotracheal intubation. It is the method of choice for emergency
airway management.1 RSI is associated with the
highest intubation success rate in the majority of emergency airway
cases and is superior to sedation alone.
There are two circumstances in which RSI may not be the first
technique of choice. Patients in cardiac or respiratory arrest,
or near-arrest, in whom a response to laryngoscopy is unlikely and
time is very limited, may be intubated without pharmacologic assistance.
The second exception is patients with anticipated airway difficulties
in whom the risks of failed intubation, bag-mask ventilation, or
rescue are considered too high to remove the patient’s
airway protection and respirations with paralysis. Although RSI-facilitated
endotracheal intubation is the foundation of emergency airway management,
providers must anticipate airway difficulties and be facile with
alternative airway techniques, bag-mask ventilation, rescue airway
devices, and surgical airways.
Endotracheal intubation is the most reliable way to ensure a
patent airway, provide oxygenation and ventilation, and prevent
Clinical assessment alone of oxygenation and ventilation may
be unreliable in a chaotic ED. Pulse oximetry and capnography help
guide decisions regarding tracheal intubation.
Equipment needed at the bedside before beginning intubation is
listed in Table 30-1.
Table 30-1 Equipment Needed
for Airway Management |Favorite Table|Download (.pdf)
Table 30-1 Equipment Needed
for Airway Management
|Oxygen source and tubing|
|Clear face masks—various sizes and shapes|
|Oropharyngeal airways—small, medium, large|
|Nasopharyngeal airways—small, medium, large|
|Endotracheal tubes—various sizes|
|Laryngoscope blades and handles|
|Water-soluble lubricant or anesthetic jelly|
|Alternative or rescue devices: laryngeal mask airway, intubating laryngeal
mask airway, Combitube® (Sheridan Catheter Corp.,
Argyle, NY), King LT® (King Systems, Noblesville,
|Surgical rescue equipment—surgical cricothyroidotomy
|Medications for topical airway anesthesia, sedation, or rapid-sequence intubation|
Rescue devices and a surgical airway option are ideally located
in a designated difficult airway cart in the ED. Similar equipment
available in pediatric sizing should also be present and is discussed
in detail in Chapter 29, Pediatric Airway Management.
When preparing for intubation, select the appropriate-size endotracheal tube (ETT)
and an additional tube (0.5 to 1.0 mm in diameter smaller), and
check the cuffs for air leaks with a 10-mL ...