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Rapid Sequence Awake Intubation

Andrew Merriman, MD, Jessica Mason, MD, Mel Herbert, MD MBBS FAAEM, and Scott Weingart, MD

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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EM:RAP 2016 July Written Summary 522 KB - PDF

It’s all fun and games until you have to intubate your friend.

Awake Intubation

Jess Mason MD, Mel Herbert MD, Scott Weingart MD and Drew Merriman MD


Take Home Points

      Patients with an anticipated difficult airway but sufficient respiratory reserve to allow preparation may be candidates to perform awake intubation.

      Use 4% lidocaine and an atomizer device to anesthetize the airway.

      Patients may be sedated with 1-2mg of midazolam or small aliquots of ketamine.



Drew Merriman, an emergency medicine resident, had experienced a sore throat for several weeks. He woke up in the middle of the night in a puddle of drool. He was unable to swallow. His voice sounded like a hot potato. He couldn’t believe it was epiglottitis. He drove himself back to the hospital because he didn’t want to be that emergency medicine resident who called an ambulance for a sore throat.


      He arrived at the triage desk and it was immediately apparent that something was wrong. The attending physician took one look at him and shoved him into a front room.  They put him on the monitor and placed on IVs. He realized that his fears were true. Everyone was starting to look frantic.


      Prior to the H. influenza vaccination, epiglottitis was primarily a pediatric disease. Rates have dropped to less than 1 per 100,000. However, in adults, the incidence has remained the same between 1-2/100,000.


      The traditional teaching for pediatrics is to keep them calm, transport them to the OR and intubate them under anesthesia. Adults may be able to cooperate. Some rural settings may not have alternatives and the ED physician will be responsible for the airway.


      Who should be intubated while awake?

o      Any patients who may be a difficult airway but are breathing enough to allow you time to prepare for an awake intubation.

o      A patient who is apneic or nearly dead won’t allow enough time for preparation of the intubation. These patients need RSI.

o      Patients with breathing issues and an airway presumed to be difficult secondary to anatomy (such a morbidly obese patient with pneumonia) can be temporized with BiPAP while you prepare for intubation. Patients with epiglottitis or other disease states affecting their airway are in a different category. You need rapid sequencing of your awake intubation. You can’t take longer than 5 minutes.


      What are the steps of a rapid sequence awake intubation?

o      You need to grab the highest concentration of a viscous type lidocaine and a tongue depressor.

o      Get a bottle of 4% lidocaine and something to atomize the 4% lidocaine. Weingart previously recommended the MADgic device, which is a flexible tube that attaches to any syringe and turns liquid into a thin spray. Now, he uses the EASY-spray. This is a reservoir that hooks up to air or oxygen and it puts out an atomized jet of the lidocaine with a tip you can direct. The nebulized lidocaine works quickly.

o      You need arm restraints, intubation devices and all of your failed airway equipment.

o      How do you prepare the patient? Put the patient in a position of comfort. Don’t make things worse by lying the patient flat.

       Merriman was only comfortable on all fours looking down.

o      Put a nasal cannula on the face and BiPAP or a non-rebreather mask depending on the situation to preoxygenate the patient.

o      Talk to the patient and put them in soft arm restraints. You don’t want them reaching up and grabbing at the tube.

o      Dry out the patient. Glycopyrrolate will take 5-10 minutes. Don’t bother. You don’t have time. Suction out the airway as best you can and pat dry their mucosal surfaces.

o      Put a blob of viscous lidocaine or lidocaine paste on a tongue depressor. Paint the back of their tongue. You can grab the tongue with a 4x4 gauze. Let this drop on their epiglottis. Use the EASY-spray or MADgic device to aerosolize the lidocaine over the posterior oropharynx. Use at least 5cc of the lidocaine for this. Direct the tip down and spray the epiglottis.

o      If you can time your spray, you may be able to achieve subglottic anesthesia. If you can’t, don’t worry about it. If you have to go through the nose, you need to give a lot of the lidocaine spray through the nostril. Take some more viscous lidocaine on your gloved pinky finger and put it in the patient’s nostril. If you can’t get it in, it probably won’t work for fiberoptic intubation through the nose. This can dilate the structures. The tube is about the same size as your pinky.

       They took a look at Merriman’s airway with the fiberoptic scope. He was gagging a little bit.

o      Sedation is a double edged sword. It makes the patient more comfortable and enhances the effects of topical anesthesia. However, you don’t want to do anything to worsen the respiratory status or cause apnea. You could use 1-2 mg of midazolam. This will cause very little sedation but causes amnesia. An alternative is to use small aliquots of ketamine (10mg at a time). This will cause some degree of dissociation. However, sometimes dissociation can lead to agitation and this is the last thing you want. If they are exhibiting increased agitation, you may want to give them a dose to fully dissociate them (probably 1-2 mg/kg). Try to avoid this if possible.

       They were unable to pass a 7-0 tube. They downsized to a 6-0 tube.

o      Ondansetron may help with the gag reflex. It probably won’t hurt. Give the patient 8mg of ondansetron.

       Once they got the tube in, they inflated the cuff and pushed midazolam. 

o      If you have video bronchoscopy available, use it. It is the least likely to cause airway irritation. However, many don’t have this available. Video laryngoscope and a bougie is another option. The patient will start coughing when the bougie goes in.  If nothing else, you can do these with standard laryngoscopy.

o      However, you should be very reluctant to use a laryngoscope in the setting of epiglottitis. You don’t want to inflame the epiglottis more. Fiberoptic bronchoscopy is the best option.

o      If you can’t pass the tube, try rotating it. Start small with a 6.5 endotracheal tube.


      Merriman woke up in the ICU. He was extubated within 12 hours. He was discharged home the following morning.


Todd H. -

good morning...

great case...

Was the intubation done thru nasal fiberoptic or oral... if oral... was the patient supine??? if oral was a bite bloc used to prevent the teeth from clamping on the tube??

Jess Mason -

The Intubatuon was oral, sitting upright, no bite block.

Todd H. -

so essentialy, you loaded the 6.5 ETT with a fiberoptic scope...hooked the scope to the screen so you could do video fiberoptic... put the pre-loaded ETT witht he scope past the oropharnx into larynx..threaded fiberoptic past vocal cords and passed tube over scope???


great job... Jessica that takes kahonas to do this on a colleague!!!
did you consider nasal...

Jess Mason -

Just to be clear, I did NOT do this intubation - just sharing the case because it is so unique with so many good learning points, I felt compelled to tell it on EMRAP. And yes, that is exactly how they did it.

Todd H. -

just curious

who did the intubation??? was it the ED team?? anesthesia???

it is still heroic work!!!!

Jess Mason -

I believe it was anesthesia, but I think ENT was there as well. Sounds like it was an all hands on deck situation.

ryan harris -

Link for ordering EZ sprayer from

Ryan M. -

Any thoughts to IV Lidocaine to blunt the wretching caused by the airway reflex?

Jess Mason -

Per Scott Weingart:

"Giving an IV anesthetic like lidocaine may sedate the patient and be counterproductive. Ondansetron may be a better choice if you really want to treat this, but I don't bother."

David L., M.D. -

This type of difficult airway (anatomy distorted at laryngeal inlet) may not allow tube passage. Any thoughts about emphasising the need to preparing for a surgical airway in this context?

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Break Through The Plateau Full episode audio for MD edition 244:17 min - 340 MB - M4AEM:RAP 2016 Juillet Résumé en Francais Français 36:30 min - 50 MB - MP3EM:RAP 2016 July Aussie Edition Australian 30:02 min - 41 MB - MP3EM:RAP 2016 July Canadian Edition Canadian 28:33 min - 39 MB - MP3EM:RAP 2016 July German Edition Deutsche 146:43 min - 202 MB - MP3EM:RAP 2016 Julio Resumen Español Español 79:25 min - 109 MB - MP3EM:RAP 2016 July Board Review Answers 162 KB - PDFEM:RAP 2016 July Board Review Questions 499 KB - PDFEM:RAP 2016 July Individual MP3 291 MB - ZIPEM:RAP 2016 July Written Summary 522 KB - PDFEMRAP Resumen en Español Julio 2016 1 MB - PDF

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