Markovchick Vincent J., Pons Peter T., Bakes Katherine M.(ed.) Emergency medicine secrets. 5th ed
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AIRWAY MANAGEMENT:
RESCUE AIRWAY DEVICES
CHAPTER 3
Barry C. Simon, MD
1. Do I really need to know about airway management?
Yes. Expeditious airway management saves lives.
2. How is the adequacy of ventilation assessed?
First, look at the patient. Cyanosis suggests profound hypoxia. Diaphoresis and somnolence
indicate hypercapnia and respiratory acidosis. Measuring the respiratory rate and assessing
the tidal volume by placing your hand over the endotracheal tube or the patient’s mouth
and nose are useful bedside clinical clues. If you are at all concerned, use a pulse oximeter.
Mild-to-moderate hypoxia can be monitored with pulse oximetry, which measures arterial
oxygen saturation. End-tidal CO
2
monitoring should be used for assessing ventilation.
3. Why do patients need airway management?
Assisted ventilation can help to decrease intracranial pressure or correct hypercarbia and
acidosis. Oxygenation may be needed in patients with severe lung disease or injury who are
unable to maintain an acceptable PaO
2
. Overcoming or preventing airway obstruction is
imperative in patients with neck trauma, epiglottitis, or airway burns from smoke inhalation or
ingestion of caustic substances. Prevention of aspiration in patients with altered mentation is
best accomplished with endotracheal intubation. Administration of intratracheal drugs (e.g.,
epinephrine, atropine, lidocaine) through the endotracheal tube is indicated in resuscitation
until an intravenous (IV) line can be established.
4. What is the most common cause of airway obstruction?
The tongue because it obstructs the airway far more commonly than do foreign bodies or
edema. With decreasing levels of consciousness, the supporting muscles in the floor of the
mouth lose tone, and the tongue falls posteriorly, obstructing the oropharynx. The fastest,
least invasive treatment modality is repositioning via the head tilt-chin lift maneuver. A
nasopharyngeal or oral airway should be inserted in a patient with ongoing upper airway
obstruction unrelieved by repositioning. Care must be taken in patients with potential or
suspected cervical spine injury.
5. What is a Combitube?
The Combitube is a dual-lumen, dual-cuffed airway. The two lumens allow ventilation whether
the tube is placed into the esophagus or in the trachea. The tube differs from the esophageal
obturator airway because it does not require an adequate mask seal to affect adequate
ventilation. This device is placed blindly and is usually placed in the esophagus. Dual balloons
are inflated to seal the device. Tube/lumen 1 is ventilated if the device ended up in the
esophagus and lumen 2 is ventilated if it was placed in the trachea. End-tidal CO
2
detectors
are used to confirm placement and ventilation.
6. What are the indications for the Combitube?
The Combitube is most useful in the prehospital setting when assisted ventilation is needed,
the providers are not trained or authorized to perform endotracheal intubation, or an attempt
at endotracheal intubation has been unsuccessful.
18
Chapter 3 AIRWAY MANAGEMENT: RESCUE AIRWAY DEVICES 19
7. What is the King airway?
This is an alternative device to the Combitube that uses a single channel to inflate both the
smaller distal (esophageal) and larger proximal (oropharyngeal) balloons. It has the additional
advantage of allowing passage of an airway exchange catheter into the trachea via its main
port to facilitate endotracheal intubation. There is less risk of overinflating the esophageal
balloon and rupturing the esophagus as can occur with the Combitube.
8. What are the relative contraindications to blind nasotracheal intubation (BNTI)?
Apnea is the most important contraindication because the chance of esophageal intubation is
unacceptably high. Because epistaxis complicates BNTI in one third of cases, the procedure is
contraindicated in patients with coagulopathies. Other routes of intubation are advisable in
patients with maxillary facial or severe nasal fractures because a false passage, severe epistaxis,
or rarely, cranial placement may occur. Hematomas, epiglottitis, and infections of the upper neck
are relative contraindications because of the risk of sudden airway obstruction or laryngospasm.
9. Name some complications of BNTI.
Hypoxia may occur during the intubation process. In addition to epistaxis and esophageal
intubation, there are other uncommon acute complications, such as avulsion of the turbinates,
avulsion of the vocal cords, and pharyngeal perforations with retropharyngeal dissection.
Significant elevation in intracranial pressure with coughing may precipitate uncal herniation in
patients with head injuries. Sinusitis may occur several days later from obstruction of the
paranasal ostia.
10. What is the laryngeal mask airway (LMA)?
The LMA (Fig. 3-1) is an irregular ovoid-shaped silicone mask with an inflatable rim connected
to a tube that allows ventilation. The device can be passed blindly with a high degree of success.
The nose of the mask is seated in the esophagus. When the rim is inflated, it prevents air from
going into the esophagus and forces air into the trachea. This is a good temporizing device until
a definitive airway can be established. All practicing emergency physicians should be familiar
with the use of the LMA.
11. What are the benefits of the LMA?
The LMA is relatively simple to place with a high degree of success even for those who are
inexperienced. The LMA should be considered the alternative airway device of choice in cases
in which traditional endotracheal intubation is not successful. The LMA and the newer
Figure 3-1. Airway rescue devices. Left, intubating laryngeal mask airway;
middle, laryngeal mask airway; right, King airway.
Chapter 3 AIRWAY MANAGEMENT: RESCUE AIRWAY DEVICES20
intubating LMA (ILMA) have the added benefit of allowing practitioners to pass an
endotracheal tube through the device into the trachea for definitive airway management.
12. What is rapid-sequence intubation (RSI)?
RSI is a method of facilitating endotracheal intubation by inducing short-term paralysis.
Because all emergency patients are at risk for aspiration, the airway must be secured as
quickly as possible. Paralysis with succinylcholine or rocuronium facilitates visualization and
tube placement and reduces complications that occur with attempts to intubate an awake,
struggling patient.
13. What are the predictors of a difficult intubation?
n
Morbid obesity
n
Abnormal facial shape
n
Buck teeth
n
Protruding/prominent tongue
n
Prominent mandible
n
Short neck/limited motion
The Mallampati score helps to predict the level of difficulty with intubation. A higher class
score predicts a greater degree of difficulty (Fig. 3-2).
14. Don’t you need to be an anesthesiologist to perform RSI? How is it done?
No. The basics can be remembered as the five Ps: preparation, preoxygenation, priming,
pressure, and paralysis (Table 3-1).
a. Prepare equipment (e.g., suction, endotracheal tube, bag, mask, laryngoscope).
b. Preoxygenate with 100% oxygen (no positive pressure) ideally for 5 minutes.
c. Pretreat with a defasciculating dose of vecuronium or pancuronium (0.01 mg/kg).
d. Prime with thiopental, 3 to 4 mg/kg, or etomidate, 0.3 mg/kg rapid IV push.
e. Apply pressure with Sellick’s maneuver (cricoid pressure) because consciousness is lost to
prevent regurgitation and aspiration.
f. Follow thiopental or etomidate immediately with 1.5 mg/kg of succinylcholine or
rocuronium 1.0 mg/kg IV push to paralyze.
g. Intubate the trachea and verify accurate placement with an end-tidal CO
2
detector.
h. Release cricoid pressure.
15. How do I preoxygenate a patient before intubation?
Bag-valve-mask ventilation is the only option in the apneic patient, even though this increases
the risk of aspiration by raising gastric pressure. If a patient is making effective respiratory
efforts, he or she should receive passive oxygenation via a nonrebreather mask on 100%
oxygen for a full 5 minutes. In the apneic patient, eight vital capacity breaths using high-flow
oxygen should be administered. Adequate preoxygenation will protect the patient against
hypoxia for several minutes despite becoming apneic after induction and paralysis.
Figure 3-2. The Mallampati class score helps to predict the level of
difficulty with intubation. The higher class score predicts a greater
degree of difficulty.
Chapter 3 AIRWAY MANAGEMENT: RESCUE AIRWAY DEVICES 21
Succinylcholine
(Anectine)
Rocuronium
(Zemuron)
Pancuronium
(Pavulon)
Vecuronium
(Norcuron)
Uses Skeletal muscle relaxation Skeletal muscle relaxation Skeletal muscle relaxation Skeletal muscle relaxation
Supplied 200-mg vial, 20 mg/mL 100-mg vial, 10 mg/mL 10-mg vial, 1 mg/mL 10-mg powder, 1 mg/mL
Cost * *** * **
Pregnancy class C B C C
Adult dose 1–1.5 mg/kg 0.6–1.2 mg/kg 0.1 mg/kg
3–4 mg/kg IM (max. 150 mg) 0.01 mg/kg priming dose 0.1–0.2 mg/kg
0.15 mg/kg priming dose 0.01 mg/kg priming dose
Pediatric dose Succinylcholine 1 mg/kg 0.6–1.2 mg/kg 0.04–0.1 mg/kg Do not administer if less
than 7 weeks of age
Use atropine prior to succinylcholine in any
child , 5 years AND any age repeat dosing
Atropine 0.02 mg/kg IV (min dose 0.1 mg, max
single dose 0.5 mg child, 1 mg adolescent)
Onset 30–60 sec 45–90 sec 1–3 min 60-sec RSI
Duration 5–10 min 20–40 min 40–60 min 0.3–5 min standard
60–120 min RSI
20–40 min standard
TABLE 3-1. PARALYTIC DRUGS
Continued
Chapter 3 AIRWAY MANAGEMENT: RESCUE AIRWAY DEVICES22
Succinylcholine
(Anectine)
Rocuronium
(Zemuron)
Pancuronium
(Pavulon)
Vecuronium
(Norcuron)
Class Ultrashort-acting depolarizing muscle
relaxant
Rapid-acting nondepolarizing
neuromuscular blocker
Long-acting nondepolariz-
ing neuromuscular blocker
Intermediate-acting non-
depolarizing neuromuscu-
lar blocker
Effects Fasciculations, increased IOP, ICP, and IGP Prolonged recovery with liver
failure, vagolytic activity may
increase HR, BP, and CO
Prolonged recovery with
liver and renal failure
Prolonged recovery with
liver and renal failure
Caution: exaggerated hyperkalemic response with
burns, spinal injury, stroke, paraplegia, neuromus-
cular disease (maximum at 7–10 days after injury)
and acidosis, sepsis, crush muscle injury
Vagolytic activity may in-
crease HR, BP, and CO
Onset and duration are
dose dependent
Onset and duration are dose
dependent
Minimal histamine or CV
effects
Histamine release, cardiac arrhythmias, espe-
cially bradycardia, consider atropine 0.01 mg/kg
Comments Refrigerate or use in 14 days Refrigerate or use in 30 days Refrigerate or use in
6 months
Mix with 10 mL sterile
H
2
O
TABLE 3-1. PARALYTIC DRUGS—cont’d
*, least expensive; ***most expensive.
Pregnancy class: B, presumed safety based on animal studies; C, uncertain safety; no human studies and animal studies show an adverse effect; D, Unsafe–evidence of risk that may in cer-
tain circumstances be justifiable.
BP, blood pressure; CO, cardiac output; CV, cardiovascular; HR, heart rate; ICP, intracranial pressure; IGP, intragastic pressure; IM, intramuscularly; IOP, intraocular pressure; RSI, rapid-
sequence induction.
Chapter 3 AIRWAY MANAGEMENT: RESCUE AIRWAY DEVICES 23
16. Which patients are likely to be difficult to ventilate with a bag-valve-mask?
Patients with:
n
Excess facial hair
n
Severe facial burns
n
Morbid obesity
n
Angioedema/facial fractures
n
Unstable facial fractures
17. What is Sellick’s maneuver?
Sellick described a method of applying pressure over the cricoid cartilage to help prevent
aspiration. Pressure should equal the amount of force it takes to cause discomfort when
pressing over the bridge of one’s nose. Pressure is applied after loss of consciousness and
is maintained until the endotracheal tube balloon is inflated and tube placement is confirmed.
Yet the evidence supporting the widespread use of cricoid pressure to prevent aspiration is
unconvincing. There is a risk that cricoid pressure may worsen the view of the larynx or can
reduce airway patency. Therefore cricoid pressure should be released if there is any difficulty
either intubating or ventilating the patient.
18. How do I remember the size of the endotracheal tube for children?
The easiest way is to carry a card in your wallet or refer to the Broselow tape. The following
formula works for persons 2 to 20 years old:
Tube size 5 (age in years 1 16) 4 4
19. Describe some of the induction drugs available for RSI.
n
Thiopental is a short-acting barbiturate that has been used by anesthesiologists for
decades. It is safe and effective with few serious complications but is a little longer acting
than many of the newer agents (10–15 minutes). Methohexital is an ultrashort-acting
barbiturate with a similar safety profile.
n
Midazolam, a benzodiazepine, has the added benefit of being reversible.
n
Propofol is a diisopropylphenol induction agent that has become popular among
anesthesiologists and emergency physicians for short outpatient procedures such as
reduction of dislocations. Its major disadvantage is a significant decrease in blood pressure.
n
Etomidate has become the most popular induction drug in emergency settings for its rapid
action, short duration, and absence of any effects on the cardiovascular system. Table 3-2
summarizes sedation and induction drugs.
20. Why is succinylcholine the most common paralyzing agent in RSI?
No other neuromuscular blocking agent has as rapid an onset of action (45–60 seconds) or
as brief a duration of activity (4–7 minutes). This provides added safety with the return of
spontaneous respiration within 7 minutes.
21. What are the theoretical risks of succinylcholine?
Despite its significant benefits, succinylcholine has many undesirable characteristics, some
of which may be dangerous. It increases intragastric, intraocular, and intracranial pressure.
Life-threatening hyperkalemia may occur in patients with neuromuscular disease or 3 to 4 days
after major burns and trauma. Severe muscle contractions cause delayed pain and occasionally
rhabdomyolysis. Rarely, it can precipitate malignant hyperthermia.
22. Are there any alternative paralytics?
n
Rocuronium is gaining popularity, and many providers prefer rocuronium over
succinylcholine. It has few complications and has an onset of action nearly as fast as
succinylcholine. Its only significant drawback is a duration of action of 20 to 40 minutes.
n
Vecuronium is another alternative, but its duration is even longer at 60 to 90 minutes.
It is a poor choice for RSI because of its slow onset of action. Newer nondepolarizing
drugs with properties similar to succinylcholine are on the horizon.
Chapter 3 AIRWAY MANAGEMENT: RESCUE AIRWAY DEVICES24
Methohexital
(Brevital)
Thiopental
(Pentothal)
Propofol
(Diprivan)
Etomidate
(Amidate)
Ketamine
(Ketalar)
Uses Sedation, induction,
anesthesia
Sedation, induction,
anesthesia
Sedation, induction,
anesthesia
Sedation, induction,
anesthesia
Sedation, induction, analgesia,
dissociative anesthesia
Supplied 500- mg powder 500-mg powder 200-mg ampule 20-mg ampule 500-mg vial
10 mg/mL 25 mg/mL 10 mg/mL 2 mg/mL 100 mg/mL
Cost * * *** * *
Pregnancy B C B C ?
Adult dose 1–1.5 mg/kg
induction dose
3–5 mg/kg induction
dose
1 mg/kg bolus then 0.5 mg/kg
every 3-5 minutes as needed
for procedural sedation
0.2–0.6 mg/kg induction
dose
1.0–2.5 mg/kg induction dose
0.25–1.0 mg/kg
sedation
0.5–1.0 mg/kg sedation Procedural sedation: 0.1 to 0.2
mg/kg IV over 30 to 60 seconds,
followed by 0.05 mg/kg every
3 to 5 minutes as needed for
procedural sedation
0.5–1.0 mg/kg IV sedation
5–10 mg/kg IM sedation
Pediatric dose 1–1.5 mg/kg 4–6 mg/kg Loading dose: 1 mg/kg IV
followed by 0.5 mg/kg every
3 to 5 min as needed for
procedural sedation
only approved for children
10 years or older; same as adult
dosing guidelines above.
1–2 mg/kg IV, 2–4 mg/kg IM
5–10 mg/kg IM
Onset 30–60 sec 30 sec 30 sec 30 sec 30 sec
Duration 5–10 min 3—5 min 3—5 min 3–10 min 5–15 min IV, 10–25 min IM
Class Ultrashort-acting
oxybarbiturate
Ultra-short thiobarbitu-
rate
Diisopropylphenol hypnotic Imidazole derivative
nonbarbiturate hypnotic
Rapid-acting dissociative
anesthetic
Effects Rapid hypnosis:
hypotension, apnea,
no analgesia, excit-
atory phenomena
(.children and el-
derly), seizure poten-
tial, bronchospasm,
pain on injection,
less fat uptake and
faster onset/recovery
than thiopental
Rapid hypnosis: hypo-
tension, apnea, no anal-
gesia, decreased ICP
and CBF, maintains CPP,
bronchospasm,
decreased IOP, pain on
injection, retrograde
amnesia
Rapid hypnosis: hypotension,
apnea, antiemetic and 103
more rapid recovery than thio-
pental, decreased IOP, ICP,
MAP, and CPP, pain on injec-
tion, myoclonus, anaphylaxis
with soy and egg allergy
Rapid hypnosis, relative CV and
respiratory
stability, no analgesia,
decreased IOP, ICP, and CBF,
maintain CPP, pain on injection,
myoclonus (decreased with
benzo/opioids), potential adrenal
suppression
Rapid dissociative state,
increased HR, BP, and mainte-
nance of airway reflexes al-
though apnea and hypotension
possible in catechol-depleted
patients, bronchodilation, anal-
gesia, increased IOP and ICP,
nystagmus, mydriasis
Comments Mix with 50 mL NS Mix with 20 mL NS Slow IV increments,
20–40 mg every 10 sec
Push slowly over 2 min
TABLE 3-2. SEDATION AND INDUCTION DRUGS
Chapter 3 AIRWAY MANAGEMENT: RESCUE AIRWAY DEVICES 25
Methohexital
(Brevital)
Thiopental
(Pentothal)
Propofol
(Diprivan)
Etomidate
(Amidate)
Ketamine
(Ketalar)
Uses Sedation, induction,
anesthesia
Sedation, induction,
anesthesia
Sedation, induction,
anesthesia
Sedation, induction,
anesthesia
Sedation, induction, analgesia,
dissociative anesthesia
Supplied 500- mg powder 500-mg powder 200-mg ampule 20-mg ampule 500-mg vial
10 mg/mL 25 mg/mL 10 mg/mL 2 mg/mL 100 mg/mL
Cost * * *** * *
Pregnancy B C B C ?
Adult dose 1–1.5 mg/kg
induction dose
3–5 mg/kg induction
dose
1 mg/kg bolus then 0.5 mg/kg
every 3-5 minutes as needed
for procedural sedation
0.2–0.6 mg/kg induction
dose
1.0–2.5 mg/kg induction dose
0.25–1.0 mg/kg
sedation
0.5–1.0 mg/kg sedation Procedural sedation: 0.1 to 0.2
mg/kg IV over 30 to 60 seconds,
followed by 0.05 mg/kg every
3 to 5 minutes as needed for
procedural sedation
0.5–1.0 mg/kg IV sedation
5–10 mg/kg IM sedation
Pediatric dose 1–1.5 mg/kg 4–6 mg/kg Loading dose: 1 mg/kg IV
followed by 0.5 mg/kg every
3 to 5 min as needed for
procedural sedation
only approved for children
10 years or older; same as adult
dosing guidelines above.
1–2 mg/kg IV, 2–4 mg/kg IM
5–10 mg/kg IM
Onset 30–60 sec 30 sec 30 sec 30 sec 30 sec
Duration 5–10 min 3—5 min 3—5 min 3–10 min 5–15 min IV, 10–25 min IM
Class Ultrashort-acting
oxybarbiturate
Ultra-short thiobarbitu-
rate
Diisopropylphenol hypnotic Imidazole derivative
nonbarbiturate hypnotic
Rapid-acting dissociative
anesthetic
Effects Rapid hypnosis:
hypotension, apnea,
no analgesia, excit-
atory phenomena
(.children and el-
derly), seizure poten-
tial, bronchospasm,
pain on injection,
less fat uptake and
faster onset/recovery
than thiopental
Rapid hypnosis: hypo-
tension, apnea, no anal-
gesia, decreased ICP
and CBF, maintains CPP,
bronchospasm,
decreased IOP, pain on
injection, retrograde
amnesia
Rapid hypnosis: hypotension,
apnea, antiemetic and 103
more rapid recovery than thio-
pental, decreased IOP, ICP,
MAP, and CPP, pain on injec-
tion, myoclonus, anaphylaxis
with soy and egg allergy
Rapid hypnosis, relative CV and
respiratory
stability, no analgesia,
decreased IOP, ICP, and CBF,
maintain CPP, pain on injection,
myoclonus (decreased with
benzo/opioids), potential adrenal
suppression
Rapid dissociative state,
increased HR, BP, and mainte-
nance of airway reflexes al-
though apnea and hypotension
possible in catechol-depleted
patients, bronchodilation, anal-
gesia, increased IOP and ICP,
nystagmus, mydriasis
Comments Mix with 50 mL NS Mix with 20 mL NS Slow IV increments,
20–40 mg every 10 sec
Push slowly over 2 min
*, least expensive; ***most expensive.
Pregnancy class: B, presumed safety based on animal studies; C, uncertain safety; no human studies and animal studies show an adverse effect; D, Unsafe–evidence of risk that may in certain
circumstances be justifiable.
BP, blood pressure; CBF, cerebral blood flow; CPP, coronary perfusion pressure; CV, cardiovascular; HR, heart rate; ICP, intracranial pressure; IM, intramuscularly; IOP, intraocular pressure; IV,
intravenously; MAP, mean arterial pressure; NS, normal saline.
Chapter 3 AIRWAY MANAGEMENT: RESCUE AIRWAY DEVICES26
23. Are there any contraindications to RSI?
Yes. Paralyze a patient only when you are sure he or she can be bag-mask ventilated if
intubation is unsuccessful. Anticipation of a difficult airway based on anatomic features or
traumatic anatomic distortion (e.g., patients with massive facial trauma or severe facial burns)
is a relative contraindication. Inability to preoxygenate patients (e.g., patients with severe
chronic obstructive pulmonary disease or asthma) is a relative contraindication to RSI.
Patients with airway obstruction (e.g., foreign body, allergic reaction, airway infections,
malignancies) who continue to make some respiratory effort should not be paralyzed.
24. How do I manage patients who have contraindications to RSI?
Nasotracheal intubation is a good alternative in patients with pulmonary disease. If
unsuccessful, or if there is a contraindication to nasotracheal intubation, awake oral intubation
with an induction agent, such as ketamine, allows the patient to maintain a certain degree
of ventilation and airway protection during the procedure. Ketamine should not be used
in patients with head injuries because it dramatically increases intracranial pressure.
Benzodiazepines, such as midazolam, may be useful for induction because they can be
reversed easily with flumazenil if the need arises. Continuous positive airway pressure (CPAP)
or bi-level positive airway pressure (BiPAP) may be used in some patients to obviate the need
for endotracheal intubation.
25. What alternatives do I have to standard RSI?
a. Cricothyreotomy, a surgical airway through the cricothyroid membrane, can be done
rapidly, although it often is complicated by hemorrhage and is contraindicated in children
younger than 8 years.
b. Tracheotomy is more time consuming but is the surgical airway of choice in children and
patients with tracheal injury.
c. Fiberoptic intubation allows visualization of the cords and trachea but is technically
difficult and time consuming.
d. In tactile intubation, the practitioner uses his or her index and middle fingers to palpate
the epiglottis and guide the tube through the cords. The patient needs to be comatose or
heavily sedated, and the success rate is lower than that of RSI.
e. Retrograde intubation involves placing a wire through the cricoid membrane and securing
it through the mouth. The wire is used as a guide to pass the endotracheal tube.
f. Percutaneous transtracheal ventilation involves inserting a catheter into the trachea via
the cricothyroid membrane and ventilating the patient with high-pressure oxygen. This is
most useful in small children because cricothyreotomy is contraindicated.
The two last techniques are used rarely and require prior training or special equipment.
26. When the patient is intubated, how do I determine if the endotracheal tube is
placed correctly?
Visualizing the tube pass through the cords is helpful but fallible. Monitoring oxygen saturation
and the use of capnography or colorimetric end-tidal CO
2
devices are standard-of-care adjuncts.
Other findings are helpful but are not definitive: The tube fogs and clears with ventilation, breath
sounds are heard in both axillae but not over the stomach, and chest expansion is noted and
symmetric.
27. Doesn’t the chest radiograph confirm placement in the trachea?
No. Although the chest radiograph is helpful in ruling out bronchial intubation, the tube easily
can be placed in the esophagus and appear to be in the trachea proximal to the carina.
Chapter 3 AIRWAY MANAGEMENT: RESCUE AIRWAY DEVICES 27
BIBLIOGRAPHY
1. Mace SE: Challenges and advances in intubation: rapid sequence intubation. Emerg Med Clin North Am
26(4):1043–1068, 2008.
2. Vrocher D, Hopson L: Basic airway management and decision making. In Roberts JR, Hedges JR, editors:
Clinical procedures in emergency medicine, 4th ed., Philadelphia, 2004, Saunders, pp 53–68.
3. Walls R: Airway. In Marx JA, Hockberger RS, Walls RM, editors: Emergency medicine concepts and clinical
practice, 6th ed., St. Louis, 2006, Mosby, pp 2–25.
4. Walls R: Airway. In Marx JA, Hockberger RS, Walls RM, et al: In Rosen’s emergency medicine, 7th ed.,
St. Louis, 2009, Mosby, pp 3–22.
KEY POINTS: AIRWAY MANAGEMENT
1. Never paralyze a patient unless you are certain that he or she can be ventilated using a
bag-valve-mask or rescue airway device.
2. Assume that all ED patients who require active airway management have a full stomach and
perform RSI to minimize the risk of aspiration.
3. Objective measures like a CO
2
detector or end-tidal CO
2
must be used to confirm endotracheal
intubation in every patient.
4. The King airway laryngeal mask device is an invaluable rescue tool that should be in practicing
emergency physicians’ armamentarium.
5. Preoxygenation with 100% O
2
for 5 minutes is a critical component of RSI intubation
preparation.