• The tongue is the most common cause of upper airway obstruction in the supine unconscious or semiconscious patient.

  • Relieve upper airway obstruction from tongue in the unconscious or semiconscious patient.
  • Adjunct to BVM ventilation

  • The oropharyngeal airway should not be used on the patient with an intact gag reflex (risk of vomiting).

  • Oropharyngeal airway
    • Insert the device while inverted → rotate 180 degree once well into the mouth → advance distal end into the hypopharynx.
      • This technique is not recommended for pediatric patients.
    • Or compress the tongue with a tongue depressor and advance the device without inversion.
  • Nasopharyngeal airway
    • Gently advance into a nostril until the flared end is resting against the nasal orifice.

  • Epistaxis (nasopharyngeal airway)
  • Vomiting and aspiration
  • Worsened obstruction from improper placement (oropharyngeal airway)

Rapid-Sequence Intubation Steps
1. Set up IV access, cardiac monitor, oximetry, and possibly capnography.
2. Plan procedure incorporating assessment of physiologic status and airway difficulty.
3. Prepare equipment, suction, and potential rescue devices.
4. Preoxygenate.
5. Consider pretreatment agents based on underlying conditions.*
6. Induce with potent sedative agent.
     - Etomidate 20mg IV
7. Give neuromuscular blocking agent immediately after induction.
      - Succinylcholine 100mg IV
8. Bag-mask ventilate only if hypoxic, consider cricoid pressure.
9. Intubate trachea after muscle relaxation has been achieved.
10. Confirm placement and secure tube.
11. Provide postintubation sedation and postintubation management.

Table 30-7 Preferred Rapid-Sequence Intubation Induction Agents
Agent Dose Induction Duration Benefits Caveats
Etomidate 0.3 mg/kg IV <1 min 10-20 min ICP Myoclonic jerking or seizures and vomiting in awake patients
Intraocular pressure No analgesia
Neutral BP Cortisol
Propofol 0.5-1.5 mg/kg IV 20-40 s 8-15 min Antiemetic Apnea
Anticonvulsant BP
ICP No analgesia
Ketamine 1-2 mg/kg IV 1 min 10-20 min Bronchodilator Secretions
"Dissociative" amnesia BP
Analgesia Emergence phenomenon
Abbreviations: BP = blood pressure; ICP = intracranial pressure