Is crash intubation necessary in every patient who collapses?

Crash Intubation in Collapsed Patients: A Risk-Stratified Approach

No, crash intubation is not necessary in every collapsed patient—the decision must be based on specific clinical indicators of airway compromise, respiratory failure, or inability to protect the airway, not simply the presence of collapse. 1

Initial Assessment Priority

When encountering a collapsed patient, immediate recognition of cardiac arrest versus other causes of collapse is the critical first step, as up to 50% of collapses are initially misidentified and this directly impacts survival. 1

Determine if the Patient is in Cardiac Arrest

• Assess for unresponsiveness with absent or abnormal breathing (including agonal gasps) to identify cardiac arrest. 1
• If cardiac arrest is confirmed, initiate high-quality CPR immediately with chest compressions at 100-120/min rather than attempting intubation first. 1
• Professional rescuers should provide chest compressions with ventilations at a 30:2 ratio for cardiac arrest victims whose airway is not secured. 1

Specific Indications for Immediate Intubation

Intubation should be performed without delay only when specific airway or respiratory criteria are met, regardless of blood pressure status or other vital signs. 2

Mandatory Intubation Criteria

• Airway obstruction preventing adequate oxygenation 2, 3
• Altered consciousness with Glasgow Coma Scale ≤ 8 2, 3
• Persistent hypoventilation or hypoxemia despite supplemental oxygen 2, 3
• Apnea or severe respiratory distress with exhaustion 2
• Inability to protect the airway with risk of aspiration 1

The CAB vs ABC Paradigm in Trauma

For collapsed patients with suspected exsanguinating hemorrhage, prioritizing circulation before airway (CAB approach) has been associated with decreased 24-hour and 30-day mortality. 4

• Delaying advanced airway management while focusing on immediate hemorrhage control and blood product resuscitation improves survival by avoiding postintubation hypotension. 4
• Oxygenation takes absolute priority over definitively securing the airway, unless airway control is required to achieve oxygenation. 3

Critical Pitfalls in Peri-Intubation Management

Cardiovascular Collapse Risk

Peri-intubation cardiovascular collapse occurs in 43.4% of critically ill patients and is associated with increased ICU mortality (OR 2.47). 5

• Avoid propofol as an induction agent in hemodynamically unstable patients, as it is independently associated with cardiovascular instability (OR 1.28). 5
• Have vasopressors immediately available, though pre-intubation fluid boluses and vasopressors have not been proven to reduce cardiovascular collapse incidence. 2, 5

Monitoring Requirements

Failure to use waveform capnography in ventilated patients contributes to >70% of ICU airway-related deaths—this is now the expected standard in the UK and should be used for all intubations. 1, 2, 3

When NOT to Intubate a Collapsed Patient

• Witnessed out-of-hospital cardiac arrest with shockable rhythm: Delay positive-pressure ventilation and provide up to 3 cycles of 200 continuous compressions with passive oxygen insufflation instead. 1
• Collapse from suspected opioid overdose with definite pulse but no normal breathing: Administer naloxone and provide bag-mask ventilation rather than immediate intubation. 1
• Neurogenic shock in spinal cord injury without respiratory compromise: Maintain airway patency with positioning and supplemental oxygen; T4 tetraplegia preserves diaphragmatic function initially. 6

Practical Algorithm for Decision-Making

1. Assess responsiveness and breathing pattern to distinguish cardiac arrest from other causes 1
2. If cardiac arrest: Begin CPR immediately, defer intubation unless ventilation cannot be achieved with bag-mask 1
3. If not cardiac arrest: Evaluate for specific intubation criteria (GCS ≤8, airway obstruction, hypoxemia, hypoventilation) 2, 3
4. If exsanguinating trauma: Prioritize hemorrhage control over airway unless airway obstruction prevents oxygenation 4
5. If intubation indicated: Use rapid sequence intubation with manual in-line stabilization, avoid propofol in unstable patients, have vasopressors ready 2, 3, 5

The key principle is that collapse alone does not mandate intubation—specific airway, respiratory, or neurological criteria must be present to justify the significant risks of peri-intubation cardiovascular collapse.