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]

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1. [1]Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Br J Anaesth, 2015.PMID 26556848
2. [2]Tran DT, Newton EK, Mount VA, et al. Rocuronium versus succinylcholine for rapid sequence induction intubation Cochrane Database Syst Rev, 2015.PMID 26512948
3. [3]Russotto V, Myatra SN, Laffey JG, et al. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries JAMA, 2021.PMID 33755076
4. [4]Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial JAMA, 2018.PMID 29800096
5. [5]Hristovska AM, Duch P, Allingstrup M, et al. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults Cochrane Database Syst Rev, 2017.PMID 28806470
6. [6]Hansel J, Rogers AM, Lewis SR, et al. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation Cochrane Database Syst Rev, 2022.PMID 35373840
7. [7]April MD, Schauer SG, Nikolla DA, et al. Association between multiple intubation attempts and complications during emergency department airway management: A national emergency airway registry study Am J Emerg Med, 2024.PMID 39288499
8. [8]Driver BE, Semler MW, Self WH, et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial JAMA, 2021.PMID 34879143
9. [9]Lascarrou JB, Boisrame-Helms J, Bailly A, et al. Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial JAMA, 2017.PMID 28118659