Airway management is an essential skill for clinicians caring for critically ill or injured patients and is fundamental to the practice of emergency medicine. In emergency medicine practice, rapid sequence intubation (RSI) is the most frequently used and successful means of intubating the trachea [1-6]. It is employed in approximately 70 percent of all patients requiring intubation in academic emergency departments, and about 82 percent of those without cardiac arrest. Cardiac arrest patients, who are intubated without medications, comprise the bulk of the remaining patients.
Although RSI is generally the preferred approach in the emergency department (ED), it may be poorly suited for some patients with difficult airway attributes. Thus, a careful assessment for airway difficulty must precede the decision to use RSI [1,3].
This topic review will discuss an algorithmic approach to advanced emergency airway management in adults. Other issues related to airway management, including basic airway management, difficult airway assessment, and rapid sequence intubation, are discussed in detail elsewhere. (See "Basic airway management in adults" and "The difficult airway in adults" and "Rapid sequence intubation in adults".)
RSI AND THE DIFFICULT AIRWAY
Clinicians should employ an approach to emergency airway management that accounts for the possibility of difficult intubation, difficult bag-mask ventilation (BMV), difficult extraglottic device ventilation (EGV), and difficult cricothyroidotomy. Methods for evaluating airway difficulty and management of difficult and failed airways are discussed in detail elsewhere. (See "The difficult airway in adults" and "The failed airway in adults" and "Emergent surgical cricothyrotomy (cricothyroidotomy)".)
In general, rapid sequence intubation (RSI) is used in patients for whom successful intubation and successful bag-mask ventilation are anticipated, despite any difficult airway attributes that may be identified. A significant number of emergency department (ED) patients in need of endotracheal intubation (ETI) have anatomic characteristics that can increase the procedure's difficulty. Nevertheless, the great majority of such patients can be managed using RSI.