Approach to Endotracheal Intubation
In general, the anesthesiologist should insist on the same monitoring
standards for airway management in the ED as in the OR, including an electrocardiogram,
blood pressure (BP), oximetry, and capnometry. Appropriate equipment should be available
in any location where emergency intubations are likely, including the ED. Such equipment
includes an oxygen source, bag-valve-mask ventilating system, mechanical ventilator,
suction, and a selection of laryngoscope blades, endotracheal tubes, and devices
for managing difficult intubations.
Intubation is almost always best accomplished with a modified
rapid-sequence approach by an operator with experience in this practice. Although
concern may exist that the use of neuromuscular blocking drugs and potent induction
anesthetics outside the OR will be associated with a higher complication rate,[12]
the opposite is in fact more likely correct. Anesthesia and neuromuscular blockade
allow for the best possible intubating conditions on the first approach to the patient's
airway, which is highly advantageous in an uncooperative, hypoxic, or aspirating
patient. Attempts to secure the airway in an awake or lightly sedated patient increase
the risk of airway trauma, pain, aspiration, hypertension, laryngospasm, and combative
behavior. Experienced providers, supported by the monitoring and equipment just
listed, have achieved results for medication-assisted intubation outside the OR that
are equivalent to those for emergency intubations within the OR ( Table
63-5
).[13]
[14]
[15]
