• General criteria for endotracheal intubation include a

failure to protect the airway, a failure to adequately

oxygenate, and a fa ilure to expire accumulating co r

• Pursue alternative techniques (eg, cricothyrotomy) in

patients when the in itial airway intervention has fa iled

and the patient cannot be adequately ventilated.

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 laryn ­

geal 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

.... History

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

CHAPTER 11

medication use and known drug allergies, and try to ascertain the immediate events leading up to ED presentation.

Risk factors predictive of a difficult airway include

those that impair adequate BVM ventilation and those that

preclude successful placement of an ETT. Examples of the

former include patients with facial trauma and distorted

anatomy, obese patients with excessive cervical soft t issue,

and asthmatic patents with excessively high airway resistances. Examples of the latter include patients with a his ­

tory of degenerative changes of the spine that limit cervical

mobility ( eg, rheumatoid arthritis, ankylosing spondylitis),

patients with underlying head and neck cancers that distort the normal cervical anatomy, and those with excessive

swelling of the airway and surrounding tissues (eg,

angioedema).

..... Physical Examination

Rapidly examine the airways of all critically ill patients.