Emergent endotracheal intubations (ETI) are typically performed in the ER, the ICU, or the general ward.

  Rapid sequence intubation (RSI)

  Rapid sequence intubation consists of several steps

  Preoxygenation

  Administration of induction agent and muscle relaxant (followed by 30 to 60 seconds delay)

  Direct laryngoscopy and endotracheal intubation

  RSI has been shown to be an effective and safe approach to airway management in critically ill patients in the emergency settings.

  Application of cricoid pressure is very controversial, as there is no strong clinical evidence of effectiveness and some evidence that it can be detrimental.

Indications

  Respiratory failure (pulmonary edema, massive aspiration, pulmonary embolism, etc.)

  Cardiac arrest/profound hemodynamic instability

  Severe metabolic acidosis (sepsis, cardiogenic shock)

  Altered mental status (stroke, intoxication)

  Inability to protect airways (upper airway hemorrhage, copious secretions)

  Trauma

Complications

  Emergent intubation carries higher than elective risk of complications: 14% to 28%

  Airway-related complications

  Difficult intubation

  Esophageal intubation

  Dental or oropharyngeal injury

  Aspiration

  Pneumothorax

  Hemodynamic complications

  Hypotension

  Cardiac arrest

  Airway management team

  Presence of additional health-care provider has been shown to decrease rate of complications.

  Presence of an anesthesiology attending has been shown to decrease the rate of complications from 21.7% to 6.1%.

Procedure

  Evaluation of the patient

  Prediction of difficult airways is extremely important before ETI.

  History of difficult airways is the best predictor of difficult ETI.

  Anesthesia/intubation records should be reviewed if available.

  Incidence of difficult intubation in OR is 1% to 8%, while outside of OR it is 8% to 12%.

  Incidence of difficult mask ventilation in OR is 1.4% to 5%, while impossible mask ventilation occurs in 0.15%.

  Predictors of difficult intubation:

  History of difficult intubation

  Mallampati score III or IV

  Limited neck range of motion

  Short thyromental distance (< 3 fingers)

  Small mouth opening (< 3 fingers)

  Predictors of difficult mask ventilation:

  Mallampati score III or IV

  History of radiation to the neck

  Presence of beard

  History of obstructive sleep apnea or snoring

  Thick/obese neck

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