Suffocation will render even the most placid individual a bit feisty. The combative patient is in greater need of emergent airway intervention than the cooperative one. In these instances it is important for the emergency physician to control the patient and use RSI to secure a stable airway. Early intubation with RSI is much better than waiting for a patient to fatigue.

Frequently, the sicker the patient, the more appropriate the use of RSI. Proper selection of sedative/induction agents manages the patient's cardiovascular, intracranial, and respiratory parameters better than forceful intubation. However, in the moribund patient who is hard to bag, an abbreviated RSI (even to the point of no RSI) may be appropriate.

It is very clear that the standard of care in emergency medicine is for emergency physicians to perform RSI using paralytics. This applies to every department, from the smallest rural facility to the largest university medical center.

This is the medical version of "If the only tool you have is a hammer, everything looks like a nail." There is no evidence that this combination is any safer than any other, nor that this combination will result in greater success rates of intubations. If anything, restricting the use of agents will increase the possibility of a complication. The safest and most successful RSI protocols allow physicians to select those agents most appropriate for the clinical circumstance.

Emergency medicine is in the business of providing emergency care. Airway management is the apotheosis of emergency intervention. If a hospital wishes to hold itself out as providing emergency care, then it must possess the equipment to manage patients with complicated airways.

Auscultation is not a valid means of confirming endotracheal tube placement. It may be accurate in many instances, and certainly listening to the chest after an intubation is instinctive. However, to be absolutely certain that an ET tube is in the trachea, a more reliable test is needed. This means either the esophageal detector device or capnometry.

Paralyzed patients don't move, but they are not asleep. It is torture to paralyze and not adequately sedate a patient. In many institutions the paralysis is used simply for the intubation while cooperation with ventilator management is performed through administration of sedatives.

Succinylcholine should not be used in those with the potential for an elevated potassium level. Patients in this category include patients who miss dialysis, patients with spinal cord injuries over a few days old, and those with serious burns or crush injuries that are several days old.

Even in children in whom a non-depolarizing blocker is to be used, it is always wise to pretreat with atropine. The simple act of laryngoscopy can lead to brady-asystole in these children, especially if they are hypoxic or acidotic.

 

 Airway management follows Murphy's Law. The middle of a resuscitation is not the time for a fire drill on the difficult airway. Problems should be anticipated and ED personnel should be schooled in how to respond to different clinical challenges.