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Establishmentofapatentairwayisthecornerstoneofsuccessfulresuscitationandadefiningproficiencyofemergencymedicine.

Basicairwaymanagementincludestheinitialairwayevaluationandidentificationanduseofinterventionstomaintainoxygenationandventilation.Theseinterventionsmightbesimple,suchastheapplicationofsupplementaloxygen,orcomplex,suchasnoninvasiveventilationoremergencytrachealintubation.

Thegoalofemergencyintubationissafe,successfulintubationofthetracheawithanendotrachealtubethatallowsoxygenationandventilationwhileprotectingtheairwayfromaspiration.

Patientsintheemergencydepartmentarealwaysconsideredhighriskbecausetheyhavenotbeenevaluatedbeforehand,mayhaveeatenrecently,mayhaveanatomicobstaclesthatarenotreadilyapparent,ormayhaveunstablehemodynamicparameters.

irritation. Patients should be asked to open their mouth, or if they are obtunded, a jaw-thrust and mouth-opening maneuver should be performed carefully to determine how far it can be opened. Palpation of facial structures includes determination of nasal, maxillary, and mandibular stability. Maxillary insta-bility, in particular, should alert the practitioner to be cautious with any nasal intubation, whether by nasal trumpet, nasogas-tric tube, or blind nasotracheal intubation, because intracranial misplacement of nasal trumpets and nasogastric and nasotra-cheal tubes has been reported.2-6 Once past the facial struc-tures, the tongue should be viewed. Similarly, the hard and soft palate, as well as the tonsils, should be evaluated.Functional assessment is performed to determine whether

the patient can move air and phonate. Specific airway noises should be noted, especially stridor.7 Such assessment leads the clinician to evaluate for specific indications for intubation (Box 1.1).8,9

Oxygenation failure can be defined as an inability to main-tain oxygen saturation greater than 90% despite optimal oxygen supplementation (the exception is a patient with chronic obstructive pulmonary failure, who typically main-tains a saturation of 85% to 90%).8,10 Ventilatory failure is usually measured by clinical features, including respiratory rate, abnormal depth or work of breathing, abnormal breath-ing patterns, accessory muscle use, inability to speak in com-plete sentences, presence of abnormal airway sounds (stridor or severe wheezing), or altered mental status. Studies also point to end-tidal carbon dioxide measurement as an aid in procedural sedation,10 but it is potentially unable to accurately predict Paco2 in patients with dyspnea.

11

Acute obtundation diminishes a patients ability to sense irritant stimuli and therefore spontaneously protect the airway.9,12 This is part of the rationale for using a Glasgow Coma Scale score of 8 or lower as a cue to intubate trauma patients.12 Traditionally, the gag reflex has been used to deter-mine whether a patients airway reflexes are intact. Stimula-tion of a gag reflex in an obtunded or trauma patient may result in unwanted patient reactions, however, such as bucking, gagging, coughing, or actual vomiting; additionally, up to 37% of healthy volunteers fail to demonstrate a gag reflex.12,13 Alternatively, a patient who swallows spontaneously while recumbent has sensory and motor paths capable of protecting the airway.12,14,15 In addition, recent articles have questioned use of the Glasgow Coma Scale score in nontrauma patients and instead emphasize clinical judgment in making the deci-sion to intubate.16,17

KEY POINTS

Rapid-sequence intubation (RSI) is the technique of combin-ing sedation and paralysis to create optimal intubating condi-tions to facilitate emergency intubation. RSI has become the standard in emergency airway management, with intubation success rates greater than 99%.1 The emergency airway opera-tor should fully understand the risks and benefits and also know when to deviate from its standard algorithm.

AIRWAY ASSESSMENT

Initial assessment of the patients airway may identify key features that will help guide airway management. This assess-ment may have to proceed simultaneously with supportive airway maneuvers.Anatomically, one should assess the patient by looking for

facial distortion and the position in which the airway is held. Drooling or inability to tolerate secretions may be apparent and are ominous signs that suggests significant supraglottic

1 Basic Airway ManagementDavid A. Caro

SECTION I RESUSCITATION SKILLS AND TECHNIQUES

1


2

Finally, the patients anticipated course will serve as an intubation criterion if loss of airway patency or protection is predicted within the near future.

CRITICAL AIRWAY PHYSIOLOGY

OXYGENATION TECHNIQUESThe binding of oxygen to hemoglobin is not linear. Hemoglo-bin tends to bind oxygen well until the partial pressure of oxygen decreases to 60 mm Hg, and then it rapidly dissoci-ates to allow diffusion of oxygen into blood and surrounding tissue. An oxygen partial pressure of 60 mm Hg correlates with an oxygen saturation of approximately 90%18 (Fig. 1.1). This is an important correlation that should be kept in mind throughout resuscitation (Table 1.1).Patients who require intubation should be preoxygenated

with a nonrebreather mask. The goal is to wash as much nitrogen out of the lungs as possible and replace it with oxygen.19-21

When the patient is paralyzed during RSI, this reservoir will permit continued delivery of oxygen to the alveoli for some time, thereby allowing the patient to maintain oxygen saturation while apneic. Five or more minutes of preoxygen-ation allows this reservoir to develop. Alternatively, if pressed for time, the patient can be asked to take eight vital capacity

Fig. 1.1 Oxygen-hemoglobin dissociation curve.Fourdifferentordinatesareshownasafunctionofoxygenpartialpressure(theabscissa).Inorderfromrighttoleft,theyaresaturation(%),O2content(mLofO2/0.1Lofblood),O2supplytoperipheraltissues(mL/min),andO2availabletoperipheraltissues(mL/min),whichiscalculatedasO2supplyminustheapproximately200mL/minthatcannotbeextractedbelowapartialpressureof20mmHg.Threepointsareshownonthecurve:a,normalarterialpressure;v ,normalmixedvenouspressure;andP50,thepartialpressure(27mmHg)atwhichhemoglobinis50%saturated.(FromMillerRD,editor.Millersanesthesia.6thed.Philadelphia:ChurchillLivingstone,2005.)

100

8070

a

P50

v

6050403020100

10 30 50 70 90 110Oxygen partial pressure (mm Hg)

Satu

ratio

n (%

)

Cont

ent m

L/L

Arterial oxygen

200

160

120

80

40

0

Supp

ly m

L/m

in

1000

800

600

100

300400500

700

200

0

Avai

labl

e m

L/m

in

800

600

400

200

0

BOX 1.1 Indications for Emergency Intubation

FailuretooxygenateorventilateFailuretoprotecttheairwayAnticipatedcoursethatwillrequireintubation

FromBarkerTD,SchneiderRE.Supplementaloxygenationandbag-maskventilation.In:WallsRM,MurphyMF,editors.Manualofemergencyairwaymanagement.3rded.Philadelphia:LippincottWilliams&Wilkins;2008.pp.47-61.Availableathttp://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0807/2007050100-d.html;http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0811/2007050100-t.html.

Table 1.1 Oxygenation Adjuncts

DEVICE RATE Fio2 (%)

Nasalcannula 2L 24

Nasalcannula 4L 27

Nasalcannula 6L 30

Venturimask 40

Nonrebreathermask 15L+ 65-70

Bag-mask(one-wayinhalationvalve+one-wayexhalationport,sealmaintainedwithoutbagging)

15L+ 90

breaths through the nonrebreather in an attempt to build as great a reservoir as possible.22 Not surprisingly, critically ill patients have decreased oxygen reserve and tolerate apnea less well than do relatively healthy subjects.19,20,23,24

Positive pressure will occasionally be required to oxygenate a patient before intubation. A critical feature of RSI is avoid-ance of active bag-mask ventilation unless it is absolutely necessary.22 Active bag-mask ventilation with oxygenation is reserved for patients whose oxygen saturation is below 90%.8 Any positive pressure ventilation will not only ventilate the lungs but also insufflate the stomach. This fact is critical to

CHAPTER 1 BASIC AIRwAy MANAgEMENT

3

the performance of RSI because a paralyzed patient is at risk for aspiration as a result of relaxed esophageal sphincter tone, especially if the stomach is distended with air.22 Active bag ventilation and oxygenation may need to be performed in patients who are experiencing acute oxygenation failure. Most adult bag-mask devices have reservoirs greater than 1 L and can deliver high-flow oxygen if a good mask seal is maintained.24-26 Alternatively, continuous positive airway pressure or bilevel positive airway pressure can provide a constant level of positive pressure support or two levels of pressure support, respectively, through a tightly fitted mask that fits over the nose or the mouth and nose27,28; if applied in a timely manner in the correct patient, the need for intubation might be averted.

Bag-Mask TechniqueBag-mask oxygenation plus ventilation is a critical skill that all airway managers must master before learning to perform RSI (Boxes 1.2 and 1.3).19 Application of the bag and mask requires proper patient positioning and correct application of a mask seal. The ideal position for mask ventilation is with the patient supine and the head and neck in the sniffing posi-tion.19 A proper mask seal is obtained by opposing the mask to the facial skin to create a good air seal. Additionally, new extraglottic devices are available that allow bag ventilation with an inflated balloon surrounding the glottis.29 These devices can also be used to ventilate and oxygenate patients who do not have contraindications (Box 1.4).7,30-37

EMERGENCY AIRWAY ALGORITHM

A patient who merits intubation and is dead or nearly so (a crash airway) requires immediate orotracheal intubation or cricothyrotomy without sedation or paralysis. A patient who

BOX 1.2 Failed Airway Fallback

Maskventilationistheinitialairwaymanagementmodalityofchoice for anypatientwho fails tomaintainadequateoxy-genationwithanonrebreathermaskorbeginstodesaturatebelow90%whileapneicduringanattemptatrapid-sequenceintubation.8

BOX 1.4 Causes of Airway Difficulty

Problemswithbagventilation:MOANS(Maskseal,Obesity,Age[>50yearsold],Neckmobility,Snores)7,30

Problems with laryngoscopy: LEMON (Look for airwaydistortion, Evaluate mouth opening and thyromentaldistance, Mallampati score, Obstruction, Neckmobility)31-37

Problems with cricothyrotomy: SHORT (previous neckSurgery,expandingneckHematomas,Obesity,previousRadiationtherapy,andTumorsandabscessesthatmightdistorttheanatomy)7

Problems with the use of extraglottic devices: RODS(Restricted mouth opening, Obstruction, Disrupted ordistortedairway,Stifflungsorcervicalspine)36

FromMurphyMF,WallsRM.Identificationofthedifficultandfailedairway.In:WallsRW,MurphyWF,editors.Manualofemergencyairwaymanage-ment.3rded.Philadelphia:Lippincott,Williams&Wilkins;2008.pp.81-93.Available at http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0807/2007050100-d.html; http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0811/2007050100-t.html.

is alive and requires intubation will force the airway manager to determine the method of intubation and what medications to use to facilitate it (Fig. 1.2).8

If the patient is not a crash airway candidate, one should plan to use medications to facilitate intubation. This step requires a determination of expected airway difficulty. Failure to evaluate and anticipate airway difficulty is one of the major causes of failure of intubation.38,39 The use of paralytics in emergency intubation requires preparation for an alternative airway in the event that a patient cannot be intubated by stan-dard means. A difficult airway may preclude the use of para-lytics altogether until the clinician can ensure glottic visualization, which is usually obtained with procedural seda-tion and topical anesthesia. The approach to a difficult airway is discussed in greater detail in Chapter 2.Unfortunately, there is no universal definition of a difficult

airway. Some patients give the clinician an immediate gestalt that their airway will be difficult. Clinicians tend to be correct when their initial reaction is that an airway will be difficult.38,39 The converse is not true. Some otherwise normal-appearing patients will have subtle anatomic differences that may make intubation difficult and are not immediately recognizable by a clinician who is not specifically evaluating for such difficulty.A number of studies have demonstrated various clinical

cues that can be used in an attempt to predict a difficult airway (see Box 1.4). No clinical sign, either alone or in combination with other signs, is 100% sensitive in ruling out a difficult airway.31-35,38,40 However, by using a combination of signs, the vast majority can be identified to make the practitioner aware of potential hazards.Identification of airway difficulty will require the clinician

to give serious thought to performing a sedated examination of the airway with topical anesthesia before proceeding to RSI with neuromuscular blockade (see Chapter 2.)

BOX 1.3 Requirements for Adequate Bag-Mask Oxygenation and Ventilation Technique

Properpositioning Sniffingpositionifpossible Airwayadjunctssuchasnasaltrumpetsororalairways

inappropriatepatientsPropermaskseal Two-persontechnique,withonesolelyresponsiblefor

themaskseal,isbest Jaw-thrustmaneuver:pullthemandibleuptothemask


4

manipulated, and the head should be maintained in a neutral position with in-line stabilization by a person designated for this task.45,46 If mobility is not an issue, the age of the patient and size of the occiput determine the need for elevation of the patients shoulders or head. Infants have a relatively large occiput with respect to their bodies and will therefore pas-sively flex their head forward when lying flat.47 This makes a more acute angle that the laryngoscopist has to navigate. The airway axes will align better if the infants shoulders are ele-vated. An adults head is relatively smaller and tends to extend at the cervicothoracic junction instead of flexing. This coun-terintuitively moves the laryngeal and pharyngeal axes into an alignment that is less parallel and can be overcome by placing a roll under the adults head.47 A key anatomic relationship to keep in mind is that the head is ideally aligned when an imaginary line drawn between the tragus of the ear and the anterior axillary line is parallel to the floor.Standard orotracheal intubation is performed with the prac-

titioner at the head of the bed looking down at the patients face. The clinician gently grasps the laryngoscope with the fingertips of the left hand. Using the right hand, the clinician opens the patients mouth in either a scissoring technique with the thumb and index finger or by grasping the mentum and moving it caudally to expose the mouth. The blade of the laryngoscope is then gently inserted into the right side of the mouth and advanced into the pharynx.The direct laryngoscope blades most commonly used for

emergency intubation are the curved Macintosh blade and the straight Miller blade. Traditional intubation with the Macin-tosh blade begins with insertion of the blade at the right corner of the mouth. The blade is advanced under direct visualiza-tion, is swept to the midline, and concomitantly sweeps the tongue to the patients left. The tip of the blade is directed into the vallecula, and the laryngoscope is then pushed up as a unit. The epiglottis is lifted up because of its connection to the hyoepiglottic ligament, which attaches to the posterior surface of the mucosa behind the hyoid and the base of the epiglottis. Lifting of the epiglottis exposes the vocal cords and glottis.Traditional intubation with the Miller blade is similarly

performed by inserting the blade in the right side of the mouth and maintaining the position of the blade on the right side of the tongue while the blade is inserted to the epiglottis, again under direct visualization. Tongue control is a major issue, with the blade pushing the tongue upward and to the left. The laryngoscope is then pushed upward to physically lift the epiglottis and expose the vocal cords.Video laryngoscopic intubation is the newest method of

orotracheal intubation and has developed into a valid option for primary intubation in the majority of patients. Multiple options exist, and each has its own method of how it is used.48 The benefit of these devices is that they routinely provide a laryngoscopic view superior to that possible with direct laryn-goscopy in the vast majority of patients in whom they are used.42,43,49,50 The angles required for passage of the tube may sometimes present the key challenge, so this is an additional focal point of training. As with any video-based system, the principal downside is the potential for obstruction of the oper-ators view if blood, vomitus, or excessive secretions are present in the oropharynx.Finally, nasotracheal intubation is another option for intu-

bation, although its use is decreasing in favor of directly

INTUBATION

Orotracheal intubation is now the preferred method of emer-gency intubation, either by direct laryngoscopy or by video laryngoscopy.44-46 The process of intubation includes proper patient positioning, clinician positioning, tool choice and assembly, and technique of laryngoscopy. In performing standard oral intubation, the patient lies flat and supine while positioning of the patients head is addressed.44 Patients with immobile cervical spines, whether secondary to trauma, arthritis, or other causes, should not have their heads or necks

Fig. 1.2 Main emergency airway management algorithm.BMV,Bag-maskventilation;OTI,orotrachealintubation;RSI,rapid-sequenceintubation;Spo2,pulseoximetry.(AdaptedfromWallsRM:Theemergencyairwayalgorithms.InWallsRM,LutenRC,MurphyMF,etal,editors.Manualofemergencyairwaymanagement.2nded.Philadelphia:LippincottWilliams&Wilkins,2004.Copyright2004:TheAirwayCourseandLippincottWilliams&Wilkins.)

3 attempts atOTI by

experiencedoperator?

Yes

Yes

Failedairway

BMV maintainsSpO2 90%?

No

No

No

PostintubationmanagementSuccessful?

Yes

Attemptintubation

RSI

No

Difficultairway

From difficultairway

Predict difficultairway?

Yes

Needsintubation

Crashairway

Unresponsive?Near death?

Yes

No


5

Table 1.2 Sedative Agents

AGENTRECOMMENDED

DOSETIME TO ONSET

DURATION OF ACTION

USEFUL ATTRIBUTES

Etomidate 0.3mg/kgIV 15-45sec 3-12min Hemodynamicstability

Midazolam(benzodiazepine)

0.1-0.3mg/kgIV 30-60sec 15-30min Commonlyused,familiarity

Ketamine 1.5mg/kgIV 45-60sec 10-20min Sympathetickick,bronchodilation

Propofol 1.5-3mg/kgIV 15-45sec 5-10min Bronchodilation

Thiopental(barbiturate)

1-6mg/kgIV


6

cases. Patients with asthma, elevated intracranial pressure, aortic dissection, hypertensive emergencies, and acute myo-cardial infarction have pathophysiology that could be wors-ened by an increase in sympathetic stimulation.67 Intravenous lidocaine, 1.5 mg/kg, has potential benefit in attenuating bronchospasm68,69 and increases in intracranial pressure70,71 when given as a premedication 2 to 3 minutes before RSI. Opioids (e.g., fentanyl, 1 to 5 mcg/kg intravenously 2 to 3 minutes before RSI) may have benefit in attenuating increases in intracranial pressure72 and reflexive, sympathetic hemody-namic responses to intubation.73,74 A body of literature indi-rectly supports the select use of these medications in critical airway management (Table 1.4). Laryngoscopy or the succi-nylcholine dosage in pediatric patients can result in

BOX 1.6 Assumptions for Emergency Rapid-Sequence Intubation

Theairwayhastobesecured.Thepatientsstomachisfull.Thepatienthasunstablehemodynamicsorhasthepotential

tobecomehemodynamicallyunstable.Thepatientsconditioniscriticalandtimeisoftheessence.

BOX 1.7 The Seven Ps of Rapid Sequence Intubation

1. Preparation (airway assessment, tool assembly,positioning)

2. Preoxygenation3. Premedications(ifindicated)4. Paralysiswithsedation5. ProtectionoftheairwaywiththeSellickmaneuver6. Passageofthetubeandconfirmation7. Postintubationmanagement

Table 1.4 Pretreatment Agents

AGENTRECOMMENDED DOSE

PROPOSED ACTION

Lidocaine 1.5mg/kgIV Bluntbronchospasm,bluntthereflexiveresponsetolaryngoscopy

Opioid(fentanyl)

1.5mcg/kgIV Bluntthereflexiveresponsetolaryngoscopy

Atropine 0.01mg/kgIV Avoidbradycardiainchildrenreceivingsuccinylcholine

BOX 1.5 SuccinylcholineCritical Points

Dose:1.5mg/kgintravenously(range,1-3mg/kg)Mechanismofaction:depolarizingneuromuscularblockade.

Succinylcholine binds to acetylcholine receptors andstimulates continual depolarization, which results inparalysis

Sideeffects: Hyperkalemia(sometimesfatalinpatientswithpreexist-

inghyperkalemia) Fasciculations Increasedintraocularpressure Increasedintragastricpressure Bradycardiainchildren Malignanthyperthermia Masseterspasminchildren(requiresanondepolarizing

agent[rocuronium,vecuronium]toovercome)

Table 1.3 Nondepolarizing Agents

AGENTRECOMMENDED DOSE

TIME TO ONSET

DURATION OF ACTION

Rocuronium 1mg/kgIV 45-60sec 30-60min

Vercuronium 0.1mg/kgIV 90-120sec 60-75min parasympathetic stimulation and resultant bradycardia, which has led some experts to advocate a pretreatment dose of atro-pine before attempts at pediatric intubation. Current recom-mendations are to use atropine for all intubations in children younger than 1 year and to have the drug available for those older than 1 year.47

PUTTING IT TOGETHER: RAPID-SEQUENCE INTUBATION

RSI is the technique of combining sedation and paralysis to create the most optimal intubating conditions during emer-gency intubation (Box 1.6).1,9,22,41,75 Seven checklist points have been identified to help clinicians prepare for emergency RSI (Box 1.7).22 Also known as the 7 Ps, this or a similar checklist can be used during each intubation in which airway managers participate.22 This tool should be viewed as a patient safety device and an error minimization instrument. As with any high-stakes activity, the use of memory aids and algo-rithms can reduce the cognitive load associated with decision making and allow the practitioner to focus on the specific task at hand.76

Protection of the airway refers to the use of cricoid ring pressure (Sellick maneuver) during the process of paralysis, intubation, and confirmation of endotracheal placement. The cricoid ring is compressed with an assistants index finger and thumb in an attempt to compress the underlying esophagus and prevent passive regurgitation of stomach contents into the trachea.77,78 The amount of force recommended is equivalent to the amount required to create discomfort when pressing with the same fingers on the bridge of the nose.19 Some studies have identified improper Sellick maneuver technique as a potential obstruction to laryngoscopy and placement of the endotracheal tube (ETT), but it might help prevent gastric


7

insufflation during attempts at bag-mask ventilation and is currently recommended if resources permit.19

The sixth step is passage of the tube. Laryngoscopy is performed at approximately 1 minute after the paralytic agent has been administered. The ETT is placed under direct vision (either line of sight or with video monitoring) through the cords and into the trachea. An adult man should typically have the tube placed orally to a depth of 24 cm, and an adult woman should typically have the tube inserted to 21 cm. A general rule of thumb is that the ETT should be inserted to three times its size.79 Placement of the ETT is considered complete once objective verification of placement has occurred, typically by end-tidal carbon dioxide detection.80,81

SUMMARY

Emergency airway management involves a combination of techniques and strategies designed to ensure success of intu-bation in critically ill patients. The approach to an emergency airway is necessarily different from that taken for an elective or urgent case. The airway manager must have a solid

foundation in ventilation techniques (bag-mask, extraglottic devices), which will be the first rescue device. Assessment of the airway is a critical skill that mandates a methodic approach to ensure that a difficult airway is recognized and appropri-ately planned for. The use of RSI has revolutionized emer-gency intubation, and a set of strategies is required to deal with routine intubations and difficult airways. Management of difficult airways is discussed in Chapter 2.

SUGGESTED READINGSHung OR, Murphy MF. Management of the difficult and failed airway. New York:

McGraw Hill; 2008.Walls RM, Murphy MF. Manual of emergency airway management. 3rd ed.

Philadelphia: Lippincott Williams & Wilkins; 2008.

REFERENCES

References can be found on Expert Consult @ www.expertconsult.com.

REFERENCES1. Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and

Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005;46:328-36.

2. Marlow TJ, Goltra Jr DD, Schabel SI. Intracranial placement of a nasotracheal tube after facial fracture: a rare complication. J Emerg Med 1997;15:187-91.

3. Martin JE, Mehta R, Aarabi B, et al. Intracranial insertion of a nasopharyngeal airway in a patient with craniofacial trauma. Mil Med 2004;169:496-7.

4. Moustoukas N, Litwin MS. Intracranial placement of nasogastric tube: an unusual complication. South Med J 1983;76:816-17.

5. Schade K, Borzotta A, Michaels A. Intracranial malposition of nasopharyngeal airway. J Trauma 2000;49:967-8.

6. Arslantas A, Durmaz R, Cosan E, et al. Inadvertent insertion of a nasogastric tube in a patient with head trauma. Childs Nerv Syst 2001;17:112-14.

7. Murphy MF, Walls RM. Identification of the difficult and failed airway. In: Walls RM, Murphy MF, editors. Manual of emergency airway management. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 81-93. Available at http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0807/2007050100-d.html; http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0811/2007050100-t.html.

8. Walls RM. The emergency airway algorithms. In: Walls RM, Murphy MF, editors. Manual of emergency airway management. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 8-24. Available at http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0807/2007050100-d.html; http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0811/2007050100-t.html.

9. Walls RM. The decision to intubate. In: Walls RM, Murphy MF, editors. Manual of emergency airway management. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 1-7. Available at http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0807/2007050100-d.html; http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0811/2007050100-t.html.

10. Deitch K, Miner J, Chudnofsky CR, et al. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med 2010;55:258-64.

11. Delerme S, Freund Y, Renault R, et al. Concordance between capnography and capnia in adults admitted for acute dyspnea in an ED. Am J Emerg Med 2010;28:711-14.

12. Mackway-Jones K, Moulton C. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Gag reflex and intubation. J Accid Emerg Med 1999;16:444-5.

13. Davies AE, Kidd D, Stone SP, et al. Pharyngeal sensation and gag reflex in healthy subjects. Lancet 1995;345:487-8.

14. Nishino T. Physiological and pathophysiological implications of upper airway reflexes in humans. Jpn J Physiol 2000;50:3-14.

15. Page M, Jeffery HE. Airway protection in sleeping infants in response to pharyngeal fluid stimulation in the supine position. Pediatr Res 1998;44:691-8.

16. Eizadi-Mood N, Saghaei M, Alfred S, et al. Comparative evaluation of Glasgow Coma Score and gag reflex in predicting aspiration pneumonitis in acute poisoning. J Crit Care 2009;24(470):e9-e470.15.

17. Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med 2009;37:451-5.

18. Miller RD. Transfusion therapy. In: Miller RD, Eriksson LI, Fleisher LA, et al, editors. Millers anesthesia [electronic resource]: expert consultonline and print. 7th ed. Philadelphia: Churchill Livingstone; 2009. p. 1739-66.

19. Barker TD, Schneider RE. Supplemental oxygenation and bag-mask ventilation. In: Walls RM, Murphy MF, editors. Manual of emergency airway management. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 47-61. Available at http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0807/2007050100-d.html; http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0811/2007050100-t.html.

20. Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997;87:979-82.

21. Henderson J. Airway management in the adult. In: Miller RD, Eriksson LI, Fleisher LA, et al, editors. Millers anesthesia [electronic resource]: expert consultonline and print. 7th ed. Philadelphia: Churchill Livingstone; 2009. p. 1573-610.

22. Walls RM. Rapid sequence intubation. In: Walls RM, Murphy MF, editors. Manual of emergency airway management. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 25-35. Available at http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0807/2007050100-d.html; http://www.loc.gov.lp.hscl.ufl.edu/catdir/enhancements/fy0811/2007050100-t.html.

23. Chiron B, Laffon M, Ferrandiere M, et al. Standard preoxygenation technique versus two rapid techniques in pregnant patients. Int J Obstet Anesth 2004;13:11-14.

24. Davidovic L, LaCovey D, Pitetti RD. Comparison of 1- versus 2-person bag-valve-mask techniques for manikin ventilation of infants and children. Ann Emerg Med 2005;46:37-42.

25. Mort TC. Preoxygenation in critically ill patients requiring emergency tracheal intubation. Crit Care Med 2005;33:2672-5.

26. Dorges V, Ocker H, Hagelberg S, et al. Smaller tidal volumes with room-air are not sufficient to ensure adequate oxygenation during bag-valve-mask ventilation. Resuscitation 2000;44:37-41.

27. Hore CT. Non-invasive positive pressure ventilation in patients with acute respiratory failure. Emerg Med (Fremantle) 2002;14:281-95.

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1 Basic Airway ManagementKey PointsAirway AssessmentCritical Airway PhysiologyOxygenation TechniquesBag-Mask Technique

Emergency Airway AlgorithmIntubationMedications, Pharmacology, and Physiologic Responses to Medication ClassesSedative AgentsNeuromuscular Blocking Agents (Paralytics)Pretreatment Agents

Putting It Together: Rapid-Sequence IntubationSummarySuggested ReadingsReferencesReferences

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