---
name: managing-airway-emergencies
language: en
description: Follows difficult airway algorithm with RSI protocols and backup airway planning. Use when managing difficult airways, planning rapid sequence intubation, or documenting airway management.
tags:
  - management
  - emergency-medicine
metadata:
  author: casemark
  practice_areas:
    - Emergency Medicine
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# Managing Airway Emergencies

Follows the difficult airway algorithm with rapid sequence intubation protocols, predictive assessment tools, and mandatory backup airway planning for every emergency intubation attempt.

## Why This Skill Exists

Airway management is the defining procedural competency of emergency medicine. Failed intubation in the ED carries a mortality rate of 25-30%, and cannot-intubate-cannot-oxygenate (CICO) scenarios, while rare (0.5-1% of ED intubations), are nearly uniformly fatal without immediate surgical airway intervention. Unlike the controlled operating room environment, ED airways present with full stomachs, cervical spine precautions, hemodynamic instability, and limited pre-assessment time.

The National Audit Project 4 (NAP4) found that poor airway planning, failure to predict difficulty, and delayed transition to surgical airway were the leading contributors to airway death. This skill enforces the cognitive framework: every ED intubation requires a plan A (primary method), plan B (alternate device), and plan C (surgical airway) before the first laryngoscopy attempt.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the indication for intubation (failure to protect airway, failure to oxygenate, failure to ventilate, anticipated clinical course)?
2. Can the patient be preoxygenated, or is this a crash airway with immediate desaturation?
3. What is the predicted difficulty? Apply LEMON assessment (Look externally, Evaluate 3-3-2, Mallampati score, Obstruction, Neck mobility).
4. What is the patient's hemodynamic status (SBP, MAP, vasopressor requirement)?
5. Is there a cervical spine concern requiring in-line stabilization?
6. What is the patient's weight (actual or estimated) for medication dosing?
7. Does the patient have any known difficult airway history (prior intubation records, MedicAlert)?
8. What equipment is immediately available (video laryngoscope, bougie, supraglottic airway, surgical airway kit)?

### Documents to Request

- Prior anesthesia records documenting airway grade or difficulty
- Current medication list (MAOIs, beta-blockers, anticoagulants)
- Allergy documentation (succinylcholine contraindications: burns, crush injury, hyperkalemia, neuromuscular disease)
- Pre-intubation vital signs and SpO2/ETCO2
- Cervical spine imaging or clearance status
- NPO status and last meal time
- Point-of-care glucose (hypoglycemia mimics obtundation)
- Prior airway imaging if available (CT neck, direct laryngoscopy reports)

---

## Step 1: Pre-Intubation Assessment and Optimization

### LEMON Difficult Airway Predictors

| Criterion | Assessment | High Risk |
|---|---|---|
| **L**ook externally | Facial trauma, obesity, beard, short neck, large tongue | Any concerning feature |
| **E**valuate 3-3-2 | 3 finger-breadths mouth opening, 3 FB hyoid-to-chin, 2 FB thyroid-to-mouth floor | Any measurement below threshold |
| **M**allampati | Sitting, tongue out, no phonation (classes I-IV) | Class III or IV |
| **O**bstruction | Stridor, muffled voice, drooling, neck mass, angioedema | Any obstructive sign |
| **N**eck mobility | Extend and flex neck | Limited (c-spine immobilization, ankylosing spondylitis, rheumatoid arthritis) |

### Preoxygenation Protocol

1. **Standard**: 3-5 minutes of tidal volume breathing on 100% FiO2 via NRB or flush-rate oxygen
2. **Apneic oxygenation**: Place 15 LPM nasal cannula under NRB during preoxygenation and leave in place during laryngoscopy
3. **Delayed sequence intubation (DSI)**: For combative patients who cannot tolerate preoxygenation—ketamine 1-2 mg/kg IV to achieve dissociation while maintaining respiratory drive, then preoxygenate
4. **BVM-assisted**: For patients already desaturating, provide gentle BVM ventilation with PEEP valve at 5-10 cmH2O
5. **Head-up positioning**: 20-30 degree reverse Trendelenburg for obese patients (ear-to-sternal-notch alignment)

---

## Step 2: Rapid Sequence Intubation (RSI) Protocol

### Medication Selection

| Agent | Induction Dose | Onset | Duration | Cautions |
|---|---|---|---|---|
| Etomidate | 0.3 mg/kg IV | 15-45 sec | 3-12 min | Adrenal suppression (single dose clinically insignificant) |
| Ketamine | 1.5-2 mg/kg IV | 30-60 sec | 10-20 min | Preferred in hypotension/sepsis; safe in head injury (old contraindication debunked) |
| Propofol | 1.5-2 mg/kg IV | 15-30 sec | 5-10 min | Causes hypotension—avoid in shock; reduce dose 50% if hemodynamically tenuous |
| Midazolam | 0.1-0.3 mg/kg IV | 60-90 sec | 15-30 min | Slowest onset, most hemodynamic depression—rarely first choice |

| Paralytic | Dose | Onset | Duration | Contraindications |
|---|---|---|---|---|
| Succinylcholine | 1.5 mg/kg IV (2 mg/kg IM) | 30-60 sec | 6-10 min | Hyperkalemia risk: burns >24h, crush injury >24h, denervation injury, rhabdomyolysis, renal failure with K >5.5 |
| Rocuronium | 1.2 mg/kg IV | 45-60 sec | 40-60 min | No absolute contraindications; sugammadex reversal available |

### Push-Dose Vasopressor for Peri-Intubation Hypotension

Prepare before induction for any patient with SBP <100 or MAP <65:
- **Push-dose epinephrine**: 10 mcg/mL (mix 1 mL of 1:10,000 in 9 mL NS); give 0.5-2 mL (5-20 mcg) IV every 1-2 minutes
- **Phenylephrine**: 100 mcg/mL boluses for pure vasodilation without chronotropy concerns

---

## Step 3: Laryngoscopy and Intubation Technique

1. Position: sniffing position (ear-to-sternal-notch alignment) or ramped for obese patients
2. First pass should be best pass—use the device the operator is most proficient with
3. Video laryngoscopy (VL) is recommended as first-line in most ED intubations (improved first-pass success, better for teaching, allows team visualization)
4. Bougie should be immediately available for every attempt—first-pass success improves from 82% to 96% with routine bougie use in difficult airways
5. External laryngeal manipulation (ELM/BURP) by the intubator's hand or assistant
6. Grade the view: Cormack-Lehane I-IV and document

**Three-attempt rule**: If the primary plan fails after a maximum of three laryngoscopy attempts (or two for experienced operators), immediately move to Plan B. Each attempt should involve a deliberate change in technique (different blade, different position, different operator).

---

## Step 4: Confirmation of Placement

Mandatory confirmation hierarchy (all three required):

1. **Primary**: Continuous waveform capnography (ETCO2)—gold standard; must show at least 3 consecutive waveforms
2. **Secondary**: Direct visualization of tube passing through cords (if using VL)
3. **Tertiary**: Bilateral breath sounds, absence of epigastric sounds, chest rise, SpO2 improvement

**False negative ETCO2**: In cardiac arrest, ETCO2 may be very low (<10 mmHg) despite correct placement due to low cardiac output—use direct visualization and clinical assessment.

**Post-intubation**: Chest X-ray to confirm depth (tip 3-5 cm above carina, approximately at T3-T4 level). Secure tube with commercial device; note depth at teeth/gums.

---

## Step 5: Failed Airway and Rescue Plan

| Scenario | Action |
|---|---|
| Can oxygenate, cannot intubate | Place supraglottic airway (iGel, LMA, King LT); consider awake fiberoptic if time permits |
| Cannot oxygenate, cannot intubate (CICO) | Immediate surgical cricothyrotomy—do not delay with additional oral/nasal attempts |
| Front-of-neck access (FONA) | Surgical technique preferred over needle cric in adults; vertical skin incision, horizontal cricothyroid membrane incision, bougie through membrane, 6.0 cuffed tube |

**CICO declaration**: Any team member can call CICO. Once declared, the team leader must verbally commit to surgical airway. Time from CICO declaration to first ventilation through surgical airway should be <2 minutes.

---

## Step 6: Post-Intubation Management

1. Confirm tube depth and secure with commercial holder
2. Initiate ventilator settings: TV 6-8 mL/kg IBW, RR 14-16, FiO2 100% initially then wean by SpO2
3. Begin post-intubation sedation and analgesia (do not leave paralyzed patient without sedation)
4. Reassess hemodynamics—positive pressure ventilation decreases preload; anticipate hypotension
5. Place OG/NG tube for gastric decompression
6. Obtain post-intubation ABG at 30-60 minutes
7. Document the procedure note completely

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Was a difficult airway assessment performed and documented before the first attempt?
2. Were Plans A, B, and C explicitly stated before induction?
3. Is waveform capnography confirmation documented for tube placement?
4. Are all medications documented with dose, time, and route?
5. Is the post-intubation ventilator setting and sedation plan documented?

---

## Quality Audit

| # | Criterion | Pass/Fail |
|---|---|---|
| 1 | LEMON or equivalent difficult airway assessment documented | |
| 2 | Preoxygenation method and duration recorded | |
| 3 | Apneic oxygenation (nasal cannula during attempt) documented | |
| 4 | Induction and paralytic agents with weight-based doses recorded | |
| 5 | Laryngoscope type (DL vs VL) and blade size documented | |
| 6 | Cormack-Lehane grade recorded | |
| 7 | Number of attempts and operator for each attempt documented | |
| 8 | Waveform capnography confirmation documented | |
| 9 | Tube size and depth at teeth recorded | |
| 10 | Post-intubation CXR obtained and interpreted | |
| 11 | Sedation and analgesia initiated post-intubation | |
| 12 | Backup airway plan stated before first attempt | |
| 13 | Push-dose vasopressor prepared for patients at hemodynamic risk | |
| 14 | Post-intubation ventilator settings documented | |

---

## Guidelines

1. **First pass success is the primary quality metric**—each subsequent attempt increases complication risk (desaturation, aspiration, bradycardia, cardiac arrest) by 7-fold after the third attempt
2. **Video laryngoscopy should be the default** in ED intubation per multiple society recommendations; direct laryngoscopy is a backup, not the standard
3. **Succinylcholine hyperkalemia risk** is from upregulated extrajunctional receptors, which takes 24-72 hours to develop after burns, crush injury, or denervation—acute presentations are safe
4. **Ketamine does NOT raise ICP** in clinical practice—the 1970s data was flawed; it is the preferred induction agent in hemodynamically unstable patients
5. **Rocuronium at 1.2 mg/kg** provides intubating conditions equivalent to succinylcholine in 45-60 seconds; lower doses (0.6 mg/kg) have slower onset and should be avoided for RSI
6. **Surgical airway is a definitive airway, not a failure**—delay in performing cricothyrotomy when indicated is the most common error in CICO scenarios
7. **Always debrief** after difficult airway events—document lessons learned for institutional quality improvement and create an airway alert in the patient's medical record