What is the recommended approach for emergent intubation?

Recommended Approach for Emergent Intubation

Rapid sequence intubation (RSI) is the recommended approach for emergent intubation in critically ill adult patients, involving administration of a sedative-hypnotic agent and a neuromuscular-blocking agent (NMBA) in rapid succession followed by immediate endotracheal tube placement. 1

RSI Protocol Components

1. Preparation

• Assemble necessary equipment: laryngoscope, endotracheal tubes of appropriate sizes, suction, bag-valve-mask, capnography
• Position patient optimally (head-elevated position when possible)
• Ensure IV access
• Apply monitoring: continuous ECG, pulse oximetry, blood pressure, capnography

2. Preoxygenation

• Administer 100% oxygen for 3 minutes or 8 vital capacity breaths
• Consider apneic oxygenation during intubation attempt
• For patients with hypoxemia, consider gentle mask ventilation during preoxygenation 1

3. Medication Administration

• Sedative-hypnotic agent options:

  • Etomidate (0.3 mg/kg IV) - preferred in hemodynamically unstable patients
  • Ketamine (1-2 mg/kg IV) - good alternative, especially in asthma/bronchospasm
  • Avoid propofol in hypotensive patients due to risk of further hypotension

• Neuromuscular blocking agent options:

  • Succinylcholine (1-1.5 mg/kg IV in adults) - onset 30-60 seconds, duration 5-10 minutes 2
  • Rocuronium (1-1.2 mg/kg IV) - onset 45-60 seconds, longer duration

4. Laryngoscopy and Intubation

• Wait 45-60 seconds after NMBA administration
• Perform direct or video laryngoscopy
• Confirm tube placement with waveform capnography (gold standard) 1
• Secure tube and document depth

5. Post-Intubation Management

• Initiate mechanical ventilation
• Provide ongoing sedation/analgesia
• Obtain chest X-ray to confirm tube position

Special Considerations

Difficult Airway

• Assess for difficult airway markers before proceeding
• Have backup devices readily available (bougie, video laryngoscope, supraglottic airway)
• Consider awake intubation for anticipated difficult airways 1

Hemodynamic Instability

• Adjust induction agent doses (consider reduced doses)
• Have vasopressors prepared and readily available
• Consider ketamine as induction agent in shock states

Increased Intracranial Pressure

• Consider lidocaine (1.5 mg/kg IV) pretreatment
• Maintain adequate blood pressure to preserve cerebral perfusion
• Avoid prolonged periods of hypoxemia

Cervical Spine Injury

• Maintain manual in-line stabilization
• Remove anterior portion of cervical collar during intubation
• Consider video laryngoscopy to minimize cervical movement 1

Failed Intubation

• Follow difficult airway algorithm
• Call for help early
• Maintain oxygenation with bag-valve-mask or supraglottic airway
• Be prepared for surgical airway if "can't intubate, can't oxygenate" situation develops 1

Common Pitfalls to Avoid

• Inadequate preoxygenation: Ensure proper preoxygenation to maximize safe apnea time
• Inappropriate medication selection: Choose induction agents based on patient's hemodynamic status
• Failure to confirm tube placement: Always use waveform capnography to confirm endotracheal intubation
• Delayed recognition of failed intubation: Have a clear plan for failed airway management
• Lack of post-intubation sedation: Provide adequate sedation immediately after successful intubation

RSI remains the standard of care for emergent intubation in critically ill adults as it optimizes intubating conditions while minimizing the risk of aspiration and complications 1, 3. The approach should be tailored based on the specific clinical scenario, with careful consideration of medication selection and potential airway difficulties.