The Physiologically Difficult Intubation

Area of Science:

• Emergency Medicine
• Critical Care
• Anesthesiology

Background:

• Intubation of critically ill emergency department (ED) patients is a frequent, high-risk procedure.
• Physiologic derangements (hypotension, hypoxemia, acidosis, RV dysfunction) increase peri-intubation cardiovascular collapse risk.

Purpose of the Study:

• To discuss critical pearls and pitfalls for intubating critically ill ED patients with physiologic derangements.
• To provide guidance on managing high-risk intubations in the ED setting.

Main Methods:

• Review of established and advanced techniques for emergency airway management.
• Discussion of specific patient populations and their associated challenges during intubation.

Main Results:

• Key considerations include preoxygenation, circulatory resuscitation, patient positioning, and room setup.
• Appropriate medication selection for rapid sequence intubation (RSI) is crucial.
• Specific challenges in patients with severe acidosis, traumatic brain injury, and pulmonary hypertension are addressed.

Conclusions:

• Effective management of critically ill ED patients requires meticulous attention to detail during intubation.
• Understanding and mitigating risks associated with physiologic derangements can improve patient outcomes.
• This chapter offers practical insights for emergency physicians performing high-stakes intubations.