1. Safety is about avoidance of vomiting and regurgitation. Vomit is the enemy of laryngoscopy (direct and video) and endoscopy, supraglottic ventilation and face-mask ventilation, and apneic oxygenation.

2. Good ventilation practices are critical. Avoid high peak pressures, high rates, and excessive volumes. This is true of mask and supraglottic ventilation.

3. Gravity—a fundamental force in the universe—should be respected. Head elevation—always higher than the stomach—is important for pre-oxygenation, alveolar patency, lessening risk of regurgitation, and improving conditions for laryngoscopy. In the trauma patient, tilt the bed feet down if the collar cannot be removed.

4. Timing is everything. Assign the registered nurse or team member who is giving the muscle relaxants the task of timing and announcing “60 seconds” after administration. Avoid jumping the gun, which can easily happen in stressed situations. Jumping into the mouth with a laryngoscope (or oral airway) may trigger a still-intact gag reflex and vomitus.

5. Muscle relaxants create better mask ventilation and also permit insertion of supraglottic airways, like laryngeal mask airways and the King LT-D. It’s not plastic in the trachea that is critical—it’s oxygenation, ventilation, and avoidance of vomit in the airway.

6. The best types of supraglottic devices in the emergency setting are those that allow gastric decompression. Overventilation can still cause regurgitation around the distal balloon of a King LT-D or the tip of the LMA in the upper esophagus. Suction aggressively first if using these devices in a soiled airway; they don’t work well blocking fluids from below.

7. Get your long-acting agent in before the patient recovers their protective reflexes, if you’re using succinyl choline and you need to go to plan B (ie, LMA or King LT-D for rescue). Many experts favor rocuronium for this very reason—if intubation fails, you are ready to insert an LMA or King LT-D immediately, and you have time for rescue intubation with an alternative technique.

8. Don’t MacGyver intubation efforts with supraglottic airways. There are ways to intubate through supraglottic airways, but blindly throwing in bougies and other nonperfected methods you’ve never used before should be avoided. Learn the details of your rescue devices and practice, practice, practice. Learn endoscopy—many new options now allow ED use of short and long scopes (endoscopic sheaths, single-use endoscopes such as the Amby aScope). For many ED providers, removing a rescue device and switching to a different oral intubation method (with nasal oxygen) may be better than trying the never-practiced route through a supraglottic airway.