Rapid airway eva luation to identify

findings indicative of a difficult airway

Difficult airway

predicted

No difficult airway

predicted

Modified approach including:

• "Awake look" intubation

• Difficult airway adjuncts

(LMA, bougie, fiberoptics, etc.)

Figure 1 1-1. Airway diag nostic algorithm. LMA, laryngeal mask airways; RSI, rapid-sequence intubation.

ridge meant to sweep the tongue to the side during insertion

to improve visualization of the vocal cords. The Miller blade

is straight in appearance and meant to directly lift the

Figure 1 1-2. Proper method of BVM ventilation.

epiglottis away from the vocal cords. It is of particular benefit in patients with very anterior airways and those with a

large "floppy" epiglottis. A size 3 or 4 Macintosh blade is

appropriate for most adult ED patients (Figure 1 1-3).

Certain clinical scenarios warrant unique modifications to standard RSI to attenuate the adverse physiologic

responses to endotracheal intubation. Pretreat head injury

patients with lidocaine (1.5 mg/kg) and a "defasciculating"

dose of a nondepolarizing neuromuscular blocker ( eg,

pancuronium 0.01 mg/kg) to limit the potential spike in

ICP that may accompany ETT placement. Pretreat most

pediatric patients with an anticholinergic agent ( eg, atro ­

pine 0.02 mg/kg) to prevent reflex bradycardia. Pretreat

patients in whom rapid elevations in either blood pressure

or heart rate would be catastrophic (eg, aortic dissection)

with an opioid analgesic ( eg, fentanyl 3 meg/kg) to limit

excessive catecholamine surges. Of note, the clinical utility

of many of these pretreatment regimens has recently come

under considerable debate.

Outside of the pretreatment agents listed previously,

the remaining RSI medications can be divided into either

CHAPTER 11

Figure 1 1-3. Equi pment needed for orotracheal

intubation in an adu lt. From left to right, laryngoscope

handle attached to Macintosh 3 blade, Maci ntosh

4 blade, Miller 4 blade, end-tidal C02 detector,

1 0-ml syringe, and endotracheal tube with stylet.

induction agents or paralyzing agents. Induction agents are

designed to elicit extremely rapid sedation to facilitate ETT

placement. A variety of medications are available, including etomidate (0.3 mg/kg), propofol (1 mg/kg), ketamine

(2-3 mg/kg), and midazolam (0.05-0. 1 mg/kg). Of these,

etomidate is used most frequently in the ED because of its

rapid onset and offset and relative hemodynamic neutrality. Avoid the use of benzodiazepines and propofol in

hypotensive patients and ketamine in patients with paten ­