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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 aspiration.


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

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 ...

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