Preparation

You need: a minimum of four people to manually immobilise the neck, apply cricoid pressure* or external laryngeal manipulation, give drugs, assist the anaesthetist and intubate.

Full monitoring: pulse oximeter, ECG, blood pressure and capnography. An assistant continuously feeling the radial pulse is very helpful.

IV access: at least 2, ideally large-bore cannulae

Drugs: induction agent, e.g. Ketamine, and muscle relaxant, e.g. Suxamethonium.

Anticipate hypotension. Have fast IV fluids running and blood available if possible. Avoid excess crystalloid.

Anticipate difficult intubation: have gum elastic bougie, laryngeal mask airway and surgical airway equipment available.

Apnoeic oxygenation: If sufficient oxygen sources are available, high flow oxygen delivered via nasal cannulae can help maintain oxygenation during apnoea provided the airway is open.

*cricoid pressure has limited evidence of benefit and can worsen laryngoscopic view but should be considered in patients at high risk of aspiration. Bimanual external laryngeal manipulation can improve the view at laryngoscopy.

Procedure

1. Loosen the collar if fitted and use manual, in-line stabilization of the cervical spine
2. Apply oxygen via nasal cannulae if available
3. Pre-oxygenate with 100% oxygen using a bag-valve mask or Waters Circuit for at least 3 minutes. Gentle assist ventilation if hypoxic
4. Give induction agent e.g. Ketamine
5. Give muscle relaxant immediately
6. Apply cricoid pressure, if used, as soon as the induction agent is given
7. Direct laryngoscopy and intubation – anticipate difficulty
8. Check correct tracheal tube position using capnography and auscultation
9. Re-assess the patient and maintain anaesthesia/sedation

Note: in trauma patients, the patient's head should be kept in a neutral position with manual in-line immobilisation of the neck.