What is the recommended approach for intubating an intoxicated patient?

Intubation of Intoxicated Patients

Intoxicated patients requiring intubation should be managed with modified rapid sequence induction (RSI) using a neuromuscular blocking agent, treating them as having a "full stomach" with high aspiration risk, while prioritizing first-pass success through optimal positioning, preoxygenation, and videolaryngoscopy when available. 1

Key Principle: Treat as Full Stomach

• All intoxicated patients must be considered at high risk for aspiration of gastric contents and managed accordingly with modified RSI technique 1
• The British Journal of Anaesthesia emphasizes that awake intubation or rapid sequence induction using the Sellick maneuver are the only safe techniques in patients at aspiration risk 1

Pre-Intubation Preparation

Aspiration Risk Reduction

• Discontinue any enteral feeding and remove gastric contents by suction before attempting intubation 1
• Apply cricoid force using standardized technique: 1 kg (10 N) while awake, increasing to 3 kg (30 N) after loss of consciousness 1
• Leave existing gastric tubes in place, as they do not compromise protection offered by cricoid force 1

Oxygenation Strategy

• Preoxygenate via tight-fitting facemask with CPAP (5-10 cm H₂O) for 3-5 minutes 1
• Apply nasal oxygen at 5 L/min during preoxygenation, then increase to 15 L/min after loss of consciousness to maintain apneic oxygenation 1
• Consider facemask ventilation with CPAP before intubation attempt if hypoxia is likely or present 1

Positioning

• Optimal head-up positioning (ramped or 25-30° head elevation) improves first-pass success and reduces aspiration risk 1

Medication Selection

Induction Agents

• Ketamine is increasingly favored in most circumstances due to hemodynamic stability, particularly important as intoxicated patients may have unpredictable cardiovascular status 1
• Etomidate may be considered in patients with severe hemodynamic instability, though recent evidence suggests it may produce less hypotension than ketamine in shock states 2
• Co-induction with rapidly-acting opioids (e.g., fentanyl) enables lower hypnotic doses, promoting cardiovascular stability 1

Neuromuscular Blocking Agents

• Rocuronium is the preferred NMBA in intoxicated patients rather than succinylcholine, providing similar intubating conditions with fewer side effects 1
• Succinylcholine should be avoided due to numerous side effects including life-threatening hyperkalemia and its short duration may hamper intubation if difficulty prolongs the attempt 1
• Use of NMBAs is strongly recommended as avoiding them is associated with increased difficulty and complications 1

Premedication Considerations

• Benzodiazepines may be useful for sedation before intubation in specific circumstances 1
• Traditional premedications (atropine, lidocaine, fentanyl) have limited evidence outside select scenarios and are not routinely recommended 2

Intubation Technique

Laryngoscopy Approach

• Videolaryngoscopy should be used if available and the operator is skilled, as it improves laryngeal view, reduces failures, and decreases airway trauma 1
• The most experienced available operator should perform the intubation 3
• Limit attempts to maximum of three; failure should prompt declaration of "failed intubation" and progression to rescue plan 1

Cricoid Force Management

• Reduce or remove cricoid force if difficulty occurs with laryngoscopy, tube passage, or facemask ventilation 1
• Remove cricoid force completely if active vomiting occurs 1
• A videolaryngoscope screen visible to the team enables real-time cricoid force optimization 1

Ventilation During Intubation

• Facemask ventilation with CPAP between attempts is recommended when hypoxia occurs or is likely 1
• Use two-person technique and oral airway adjuncts if facemask ventilation proves difficult 1
• Avoid high respiratory rates and volumes that may cause hypotension 1

Critical Pitfalls to Avoid

Common Errors

• Do not withhold intubation based solely on GCS score; clinical assessment by experienced staff regarding airway protection and ventilatory adequacy is more important than GCS alone 4
• Avoid blind nasotracheal intubation in intoxicated patients—it has significantly lower success rates (65% vs 100%), longer intubation times (276 vs 64 seconds), and higher complication rates including epistaxis (69%), vomiting (17%), and aspiration (10%) compared to RSI 5
• Do not delay intubation in the presence of inadequate airway protection or ventilatory failure, as these are the key clinical indicators rather than specific physiological parameters 4

Hypoxia Management

• If adequate oxygenation cannot be achieved before intubation despite optimization, proceed with intubation while maintaining peroxygenation, as prolonged delay may worsen outcomes 1
• Have rescue oxygenation with second-generation supraglottic airway immediately available if facemask ventilation fails 1

Confirmation and Post-Intubation

• Confirm successful tracheal intubation by waveform capnography 1
• Ensure full monitoring and rescue equipment available throughout the procedure 3