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MAXIM: Think before you paralyze.


Before committing to rapid-sequence induction (RSI) for direct laryngoscopy, consider the following:

  1. Are any planned medications contraindicated?

  2. Can rescue ventilation be achieved?

  3. Is direct laryngoscopy possible? (See Fig. 22.9.)

  4. What are my secondary and tertiary backup plans in the event of primary plan failure (can’t intubate, can’t ventilate)?

  5. Are my equipment and personnel ready for RSI? (See Figs. 22.12, 22.13, 22.14.)

  6. Is patient resuscitation required prior to RSI? Does the patient require crystalloid, blood, or vasopressors prior to intubation to avoid cardiovascular collapse?


Wired Mandible. This 33-year-old male had recent mandibular wire fixation of his mandibular fracture. A nasal or neck approach would be the only options for an emergency airway in this patient if no wire cutters were available. (Photo contributor: David Effron, MD.)

FIGURE 22.10

Difficult Intubation. This morbidly obese man with no identifiable neck landmarks and bushy beard was successfully intubated after the third attempt. Ventilation was extremely difficult after paralysis. (Photo contributor: Lawrence E. Heiskell, MD.)

FIGURE 22.11

Difficult Intubation. Anticipation of difficulty ventilating this patient if paralyzed prompted planning to optimize intubation success, which required three attempts. (Photo contributor: Lawrence E. Heiskell, MD.)

FIGURE 22.12

Airway Equipment Place Map. An equipment place map is a quick visual que to ensure all my equipment is present. Each item is placed over the silhouette. ETT, endotracheal tube; LMA, laryngeal mask airway. (Photo Contributor: Kevin High, RN.)

FIGURE 22.13

Prearrival Airway Checklist. Preintubation checklists are associated with a reduction in intubation-related complications and a decrease in paralysis-to-intubation time. BVM, bag-valve-mask; EM, emergency medicine; ETCO2, end-tidal carbon dioxide; IVF, intravenous fluid; LMA, laryngeal mask airway; NC, nasal cannula.

FIGURE 22.14

Preinduction Timeout Checklist. Checklists for a critical procedure like intubation improve procedural success and patient safety. BP, blood pressure; ED, emergency department; EM, emergency medicine; IV, intravenous; LMA, laryngeal mask airway; NC, nasal cannula; RSI, rapid-sequence induction.


  1. A good backup plan for direct laryngoscopy should have at least one alternative intubation technique, one alternative ventilation technique, and one surgical airway technique.

  2. Prepared equipment, correct patient position (Fig. 22.15), proper drug dosing, having a backup plan, effective communication, and good technique will promote first-pass intubation (see Figs. 22.10 and 22.11).

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