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Key Points

  • Rapid-sequence intubation (RSI) is the preferred method for endotracheal tube placement in the emergency department.

  • The decision to intubate should always be made on clinical grounds. Time permitting, assess for factors predictive of a difficult airway before RSI.

  • General criteria for endotracheal intubation include a failure to protect the airway, a failure to adequately oxygenate, and a failure to expire accumulating CO2.

  • Pursue alternative techniques (eg, cricothyrotomy) in patients when the initial airway intervention has failed and the patient cannot be adequately ventilated.


Successful airway management depends on the prompt recognition of an inadequate airway, the identification of risk factors that may impair successful bag-valve-mask (BVM) ventilation or endotracheal tube (ETT) placement, and the use of an appropriate technique to properly secure the airway. The decision to intubate is a clinical one and should be based on the presence of any 1 of 3 major conditions: an inability to successfully protect one's airway against aspiration/occlusion, an inability to successfully oxygenate the blood (hypoxemia), or an inability to successfully clear the respiratory byproducts of cellular metabolism (hypercapnia). Additional indications including the desire to decrease the work of breathing (sepsis), the need for therapeutic hyperventilation (increased intracranial pressure [ICP]), and the need to obtain diagnostic imaging in noncooperative individuals (altered mental status) should be taken into account on a patient-by-patient basis.

Techniques for the management of unstable airways range from basic shifts in patient positioning to invasive surgical intervention. Standard basic life support recommendations such as the head-tilt chin-lift maneuver may open a previously occluded airway. Oropharyngeal and nasal airway adjuncts are both simple to use and highly effective in this setting, but are unfortunately often underutilized. Failure to respond to these measures warrants the placement of an ETT. Rapid-sequence intubation (RSI) combines the careful use of pretreatment interventions with the administration of induction and paralytic agents to create the ideal environment for ETT placement and is the preferred method in the emergency department (ED).

A patient who cannot be intubated within 3 attempts is considered a failed airway. This scenario occurs in ~3–5% of all cases. Numerous alternative devices including laryngeal mask airways (LMA), introducer bougies, and fiberoptic instruments have been developed to facilitate airway management in these situations. That said, these methods are not failsafe, and roughly 0.6% of patients will require a surgical airway. Emergent cricothyrotomy is the preferred surgical technique for most ED patients.

Clinical Presentation


The need for immediate airway intervention in emergency situations always supersedes the need for a comprehensive history and physical exam. Time permitting, perform a rapid airway assessment to identify any risk factors predictive of a difficult airway, inquire about any current medication use and known drug allergies, and try to ascertain the immediate events leading up to ED presentation.


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