In some very ill patients, it may be necessary to avoid intubation if at all possible. I recently had a patient in complete heart block with hypotension from an anterior-inferior ST-segment elevation myocardial infarction. With pacing and vasopressors, she arrived to the cath lab in time, and intubation was completely avoided. In hindsight, I think she would not have tolerated the hemodynamic consequences of intubation.

As the bar of practice in emergency airways continues to be raised, as we are more and more becoming critical care doctors (by default, the way our EDs are running), it’s important to expand our perspective. Placing plastic in the trachea is but one part of our critical care responsibilities. Along with optimizing oxygenation prior to intubation (nasal oxygenation, DSI, ketamine assisted intubation, etc.), assessing Shock Index is helpful in identifying patients who need resuscitation sequence intubation, not rapid intubation.

References

1. Weingart SD, Trueger NS, Wong N, et al. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015;65:349-355.
2. Calder I, Yentis SM. Could ‘safe practice’ be compromising safe practice? Should anaesthetists have to demonstrate that face mask ventilation is possible before giving a neuromuscular blocker? Anaesthesia. 2008;63:113-115.
3. Warters RD, Szabo TA, Spinale FG, et al. The effect of neuromuscular blockade on mask ventilation. Anaesthesia. 2011;66:163-167.
4. Heffner AC, Swords DS, Neale MN, et al. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84:1500-1504.