Difficult emergency airway management algorithm

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

* 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.

Refer to UpToDate topics on RSI for further detail.

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

¥ Needle cricothyrotomy may be performed on patients of any age but is preferable to surgical cricothyrotomy in infants and children up to 10 to 12 years of age because it is easier to perform with less potential damage to the airway. For older patients, surgical cricothyrotomy is typically chosen. For a description of these procedures, refer to UpToDate content on needle and surgical cricothyrotomy.