By: Parrish T. Eilers, MD
LSU Emergency Medicine
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The Emergency Medicine Physician should be
proficient in the assessment and management
of all types of patient airways, regardless of
age, gender, or level of difficulty.
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By the end of this lecture, students should able
to:
A) Properly assess a patient’s airway.
B) Discuss techniques for properly ventilating
a patient.
C) Identify tools and proper technique needed
for intubating a patient.
D) Discuss RSI
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1) Failure to oxygenate or ventilate
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2) Unable to protect their airway
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3) Expected Clinical Course
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The first step needed before intubating any
patient, should be to assess their airway.
Steps needed for airway assessment, should
start with can I properly ventilate this patient
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Ventilation is the exchange of air between the
lungs and the environment, including
inhalation and exhalation.
Endotracheal Intubation is the placement of an
airway into the trachea for airway
maintenance.
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Requirements for bag mask ventilation:
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Need to have an open airway
Need to have a proper mask seal between the patient
and your mask
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Evaluating for bag mask ventilation difficulty
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MOANS
M: Mask Seal
 O: Obesity
 A: Age(>50 years)
 N: Neck Mobility
 S: Stiff(ie lung stiffness)
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Patients should ideally be supine in the
“sniffing” position
Mask should cover the nose and mouth of the
patient
Bring the patient’s face UP to the mask, by
holding onto the mandible, not the soft tissue
under the chin. Don’t push the mask down on
a patient’s face.
Can use oral or nasal pharyngeal airways to
assist with bagging
Two rescuer technique is best
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Evaluating for Difficult Intubation
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LEMON
L: Look for any anatomy distortion
 E: Evaluate using 3-3-2 method
 M: Mallampati score
 O: Obstruction, any signs of
 N: Neck Mobility
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After assessing the airway, begin by looking down at
the patient’s face from above the head. Then you
gently scissor open the patient’s mouth, with your
right hand. With the laryngoscopic blade in your left
hand, insert it into the right side of your patient’s
mouth and advance it along the tongue. If using a
MAC blade, advance to the base of the tongue or the
vallecula and sweep the tongue to the left. While
doing this you’re also pulling your blade towards their
feet. If using the Miller blade, then advance to the
epiglottis and place the tip of your blade on the
epiglottis. Then you sweep the tongue to the left and
pull your blade towards your patient’s feet, lifting the
epiglottis. Your Goal is just below the epiglottis.
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1) Preparation
2) Preoxygenation
3) Pretreatment
4) Paralysis with Sedation
5) Protection of Airway(Sellick manuver)
6) Pass the Tube( with Confirmation)
7) Postintubation Management
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Preparation is key to intubating your patient
and should begin before your patient even
arrives at the hospital.
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Oxygen with Bag/Mask and NRB
Suction
Endotracheal tubes
Oral and Nasal Airways
Syringe
Laryngoscope Blade with working Handle
Bougie, LMA
Mask with Face shield and Gloves
Surgical airway Equipment
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All patient’s should be pre-oxygenated with
100% O2 by NRB or Bag/Mask for 2 minutes
prior to intubation, even if they’re sats are
100% by NC O2.
Because you want to blow off as much
Nitrogen as possible and saturate your
patient’s alveoli with oxygen.
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Give drugs to aid with the physiologic
responses of intubation
Lidocaine--------blunts bronchospasm and the reflex
response
 Opioid(Fentanyl)---------blunts reflex response
 Atropine--------to avoid bradycardia in kids receiving
Succinylcholine
 Depolarizing Agent----- to attempt to prevent
fasciculations
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Give your RSI drugs, sedation first and then
your paralytic. Usually pushed one right
behind the other.
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Common Paralytics
 Succinylcholine
 Rocuronium
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Common Sedatives
 Etomidate
 Ketamine
 Ativan
 Versed
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The airway is usually protected by using the
Sellick maneuver or cricoid pressure, during
paralysis, intubation, and confirmation of tube
placement. The cricoid ring is compressed
with the assistant’s index finger and thumb.
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The tube is placed by direct visualization of the
tube passing through the vocal cords. Inserted
to a distance of about 3 times the tube size.
Usually about 24cm in adult males and about
21 in adult females. Verify tube placement by
watching the tube go through the cords, CO2
detector, auscultation of bilateral breath
sounds, and CXR.
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Don’t forget long term sedation and vent
settings. Also don’t forget to check your
postintubation CXR.