The Physiologically Difficult Intubation

Emerg Med Clin North Am. 2022 Aug;40(3):615-627. doi: 10.1016/j.emc.2022.05.011. Epub 2022 Jul 9.


Emergency physicians intubate critically ill patients almost daily. Intubation of the critically ill emergency department (ED) patient is a high-risk, high-stress situation, as many have physiologic derangements such as hypotension, hypoxemia, acidosis, and right ventricular dysfunction that markedly increase the risk of peri-intubation cardiovascular collapse and cardiac arrest. This chapter discusses critical pearls and pitfalls to intubate the critically ill ED patient with physiologic derangements. These pearls and pitfalls include appropriate preoxygenation; circulatory resuscitation; proper patient position and room setup; selection of medications for rapid sequence intubation; and intubation of patients with severe acidosis, traumatic brain injury, and pulmonary hypertension.

Keywords: Intubation checklist; Peri-intubation cardiac arrest; Peri-intubation cardiovascular collapse; Preintubation hypotension; Preintubation hypoxemia; Shock index.

Publication types

  • Review

MeSH terms

  • Acidosis*
  • Critical Illness
  • Humans
  • Hypotension*
  • Intubation, Intratracheal
  • Shock*