Emergency airway management is high-risk and involves multiple decisions. Rapid sequence intubation, which usually occurs after administration of a sedative-hypnotic agent and a neuromuscular blocking agent in rapid succession, should optimize the chance of successful intubation while reducing peri-intubation risks such as aspiration or hypotension. The Society of Critical Care Medicine developed guidelines to optimize rapid sequence intubation.

POSITIONING

Simulation studies suggest that sitting a patient up from the traditional supine position to a semi-Fowler position (ie, head and trunk raised) before intubation decreases aspiration risk, increases lung volumes, and improves intubation success through better views. The guideline suggests semi-Fowler positioning based on very low-quality evidence from conflicting studies. Although simulation and observational studies clearly demonstrate improved first-pass intubation success with semi-Fowler positioning compared with the supine position, the few randomized trials demonstrated no difference between the two positions.