Difficult emergency airway management algorithm

RSI: rapid sequence intubation; SpO₂: oxygen saturation; PIM: post-intubation management; BMV: bag-mask ventilation; EGD: extraglottic airway device; NMBA: neuromuscular blocking agent.

* Predicting the difficult airway is discussed in the UpToDate topic and includes assessment tools such as the LEMON mnemonic.

¶ This situation is further discussed in the UpToDate topic and includes, for example, a patient who is agitated and unable to cooperate or a patient with rapidly progressing airway swelling.

Δ Triple setup implies a primary intubating plan is in place, followed by a nonsurgical rescue device (eg, EGD), and lastly a surgical rescue plan (most often an open surgical bougie-assisted cricothyrotomy).

◊ During RSI, physiologic derangements such as hypotension and hypoxemia increase the risk of cardiovascular collapse during the peri-intubation period. Possible mitigating interventions include the following:

• In the hypotensive patient – An intravenous bolus of isotonic fluid and push-dose vasopressors.
• In the hypoxemic patient – Administration of high-flow oxygen and apneic oxygenation.
• In the patient with severe metabolic acidosis – Treat the underlying etiology and perform awake technique if period of apnea contraindicated.

Please refer to UpToDate topics on RSI for further detail.

§ The minimum age/weight limit for an intubating EGD is 12 yrs/30 kg.