Initial examination of patients presenting to the emergency department should include immediate assessment of the need for aggressive airway management (Table 2-1).

A decreased level of consciousness is a key indicator of patients who may have inadequate ventilation, inability to protect their airway from aspiration, and upper airway obstruction (commonly the tongue).

Measure the patient’s response (eye opening, verbal response, motor response) after rapid delivery of a verbal or painful stimulus, and quickly calculate the Glasgow Coma Scale (Table 2-2).

Useful guidelines include “less than eight, intubate,” or intubation if ten or less in the trauma patient.

Rapidly assess response to naloxone and flumazenil (if benzodiazepine overdose is suspected) and the glucose level (Dextrostix or glucometer).

Early identification of patients with elevated intracranial pressure (trauma, decreased level of consciousness, papillary signs) may allow hyperventilation to produce immediate benefit before neurosurgical intervention.

Hypoxemia may be rapidly identified by the presence of cyanosis; however, severely anemic patients may not show this important sign.

Agitation, particularly in the elderly, may be an indicator of hypoxemia.

Rapidly assess respiratory effort, including ventilatory rate, accessory muscle use, retractions, and sounds of small (wheeze) and large (stridor) obstructive airway disease.

Monitor those individuals very closely, including the very young and the very old, who are not capable of maintaining the work of breathing given their reduced muscle mass and cardiac reserve.

Anticipating airway obstruction and early intervention are crucial in the management of facial burns, inhalation injuries, and caustic ingestions.

Attempt to locate family, surrogates, advance directives, or living wills in very elderly or debilitated patients to ensure that aggressive airway management is truly in the best interest of the patient and family.

Before consideration of RSI, the airway management team (two to three persons) must achieve stabilization of the patient using basic airway techniques. This “buys time” for controlled preparation of equipment, pharmacologic agents, and definitive
airway procedures. Basic airway control also reassures the clinical team and brings order to the chaos of early resuscitation. Failure to do so invites worsening hypoxemia, hypercarbia, aspiration, raised intracranial pressure, and cervical spine injury, and negates the benefits gained by early intubation.

Breathe for the patient using a bag-valve-mask device. Mask designs using balloon or “jellyfish” design allow adequate sealing around the face and mouth with minimal operator effort, despite facial hair or an edentulous patient. Discriminating use of physical restraint in the combative patient may be essential to prevent further patient or staff injury.

Provide an Airway for the patient using an initial jaw thrust or sniffing position if cervical spine injury is not suspected. An oropharyngeal or nasopharyngeal airway may be tolerated if the patient is significantly obtunded.

Suction the patient to help prevent aspiration; the Selleck maneuver (cricothyroid cartilage pressure) may also prevent aspiration.

Ensure that the oxygen tubing is attached and that the patient has high levels of Inspired oxygen saturation or FIO₂. This saturation and denitrogenation can be achieved by 4 to 5 minutes of breathing 100% oxygen via a nonrebreather facemask or four maximally deep breaths or bag-valve-mask ventilation. The pulse oximeter can be invaluable in assessing the adequacy of oxygenation and as reassurance of oxygen delivery during preparation and actual RSI procedure.

Finally, protect the C