Airway management and rapid sequence intubation

The airway is the first letter of the primary survey for a reason: without a patent, protected airway and effective oxygenation, no other resuscitation matters. In the emergency department the definitive airway — a cuffed tracheal tube — is required whenever the patient cannot maintain or protect their own airway, cannot be oxygenated or ventilated, or is expected to follow a course that will compromise these. Rapid sequence intubation is the technique used to achieve that tube swiftly while minimising the risk of aspiration in a patient who has not fasted and whose physiology is precarious. It is one of the highest-stakes procedures in emergency medicine: it is performed frequently, it is time-critical, and its complications — hypoxia, hypotension, oesophageal intubation, and peri-intubation cardiac arrest — are common and dangerous. ^[1]

Indications for a definitive airway

A definitive airway — a cuffed tube in the trachea, secured and ventilated — is indicated when the patient fails one of three tests. Failure to maintain the airway: the obtunded patient whose tongue or secretions obstruct, or the patient with soft-tissue swelling from anaphylaxis, burns or infection. Failure to protect the airway: the patient with a reduced conscious level who cannot guard against aspiration, classically the patient with a Glasgow Coma Score of 8 or below. Failure to oxygenate or ventilate: the hypoxaemic patient despite supplemental oxygen, the tiring patient in respiratory failure, or the patient who cannot be ventilated with a bag-valve-mask. A fourth indication is the anticipated course: the patient who will predictably lose the airway, such as the rapidly progressing airway burn or the patient about to undergo a time-critical procedure for which a secure airway is a prerequisite. The decision is clinical and made early, before the patient arrests. ^[1]

References9ShowHide

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