CHAPTER 213

TRACHEAL INTUBATION
Scott Savage

Airway emergencies can be some of the most daunting situations a

practitioner encounters. Radical advances in airway management
have been made and are reviewed here.

INDICATIONS
Hypoxia
Respiratory distress
Protection of the airway
Cardiopulmonary arrest
Need to maintain hyperventilation (e.g., with traumatic brain
injury)

CONTRAINDICATIONS
Cervical spine injury (may use video and optical laryngoscopes,
fiberoptic laryngoscope, or digital [tactile] technique)
Cervical spine severely immobilized due to arthritis (may use
video and optical laryngoscopes, fiberoptic laryngoscope, or
digital [tactile] technique)
Expanding neck hematoma (relative, must use caution but may
require surgical airway)
Uncontrolled oropharyngeal hemorrhage (relative, may require
surgical airway)
Intact tracheostomy or stoma (replace tracheostomy tube)
Combative patient (consider rapid-sequence intubation [RSI]
described in this chapter)
Trismus (consider RSI or nasotracheal intubation)
Severe facial or neck trauma (consider needle or surgical cricothyroidotomy; see Chapter 199, Cricothyroid Catheter Insertion,
Cricothyroidotomy, and Tracheostomy)

Capnograph, carbon dioxide detector, esophageal detector or

other device to confirm tube placement
Suction system with dental or Yankauer tip in children and
adults, DeLee suction in neonates
Stethoscope
Cardiac monitor and defibrillator
Blood pressure monitor
Gloves
Face mask, goggles or eye shield, and any other equipment necessary to follow universal blood and body fluid precautions
Intravenous line (if possible)
Ventilator
Cricothyroidotomy kit
Sedative medication to use for chemical restraint (e.g., propofol,
benzodiazepines)

CRICOID PRESSURE (SELLICK MANEUVER)

Providing or performing cricoid pressure may help protect against
regurgitation of gastric contents; it also increases visibility by moving
the trachea into the visual field of the person intubating. To perform
cricoid pressure (Sellick maneuver), first find the thyroid cartilage
(Adams apple), and then the small indentation beneath it (cricothyroid membrane). The cartilage beneath this small indentation is
the cricoid bone. Cricoid pressure is performed by pinching the
extended thumb, index, and middle finger together into a double
V, or tripod. This is then placed on the cricoid bone and pressed
down with enough pressure to occlude the esophagus (Fig. 213-2).
The pressure should be applied toward the patients back and the
head somewhat. Cricoid pressure should not be released until intubation is completed and confirmed and the cuff inflated.
The effectiveness of the Sellick maneuver has been questioned. Because of the wide variation in pressure applied by operators, cricoid pressure should be removed if there is difficulty in
visualizing the airway.

NOTE:

EQUIPMENT
See Figure 213-1.
Laryngoscope (and fresh batteries)
Laryngoscope blades (at least two different types)
Endotracheal tubes
Adult men sizes 7 to 9
Adult women sizes 6 to 8
Nasotracheal intubation sizes 5 to7
Pediatricsconsult Broselow tape or use the size equal to the
width of the fingernail of the little finger. Use uncuffed tubes
in infants and small children up to 8 years of age.
Water-soluble lubricant
10-mL syringe
Umbilical tape or endotracheal tube holding device
Scissors
Bag-valve-mask device (Ambu-bag) with 100% oxygen delivery
system
Pulse oximeter

AIRWAY ASSESSMENT
Begin with the patient on 100% nonrebreather mask if spontaneously breathing. The jaw thrust maneuver can be used to keep the
airway open (Fig. 213-3), or begin bag-valve-mask breathing with
a second assistant providing cricoid pressure (Sellick maneuver).
The practitioner should be familiar with the anatomic landmarks
(Fig. 213-4). Many airway management failures can be traced to lack
of airway assessment. Patients can be classified into three groups
(shades) based on two criteria: anticipated difficulty in intubation
and ability to maintain oxygen saturation greater than 90% by bagvalve-mask ventilation. Airway assessment is critical. An experienced person can assess an airway in less than 4 seconds, and an
inexperienced person should be able to do so in less than 8 seconds.
The mnemonic for assessing difficulty in intubation is
332-NUTS:

1457

1458

HOSPITALIST
Straight blades

Stylet

Laryngoscope
Endotracheal
tubes
Oxygen setup
Batteries

Tape

Suction
setup

Scissors
Anesthesia and
bag valve masks

Figure 213-1 Suggested intubation equipment.

3fingerbreadths, mouth opening

3fingerbreadths, mentum (distance from the tip of the chin to
the anterior soft tissue of the neck)
2fingerbreadths, thyromental distance (distance from the top
of the thyroid cartilage to the upper soft tissue angle of the neck)
NNormal neck flexion
UUvula visible when opening the mouth
Tno Tension pneumothorax
Sno Soup (foreign body in the airway)
Meeting all these criteria indicates a low-risk intubation; conversely,
the fewer the criteria present, the higher the risk. Although the last
two categories, tension pneumothorax and soup, do not strictly
determine the anatomic difficulty of intubation, establishing their
absence is a vital part of early airway assessment. The Mallampati
system has previously been used to assess the uvular portion of the
mnemonic; however, it is important to note that this classification

Figure 213-2 Sellick maneuver. Either the practitioner or assistant uses

the thumb and index and middle fingers pinched into a double V or tripod.
Posterior pressure is then applied to the cricoid to avoid aspiration and
bring the larynx into view. Note the upward and forward direction of forces
applied in a nonfulcrum manner by the laryngoscope.

was designed to assess a patient sitting upright with voluntary mouth

openinga condition rarely encountered in clinical practice outside
anesthesiology. A simpler method is to open the mouth with the
thumb while standing to either side of the patients head. (Standing
at the head of the patient changes the angle of view, and may
produce a false result). If any portion of the uvula can be seen, then
intubation will likely be unimpeded by this factor. The three risk
groups (shades) are as follows:
Pinkable to keep the oxygen saturation greater than 90%;
anticipate easy intubation and use standard technique.
Purpleable to keep the oxygen saturation greater than 90%,
but anticipate difficult intubation. Attempt awake laryngoscopy.
If successful, perform an assisted intubation with a gum elastic
bougie, intubating or fiberoptic laryngoscope, lighted stylet, or
similar device. If not, use an intermediate airway (laryngeal mask
airway [LMA] or King LTS-D) if possible, and obtain expert
assistance for further management.
Blueunable to keep the oxygen saturation greater than 90%.
If possible, perform a single attempt at an intermediate airway
(LMA or King LTS-D). If successful and easy intubation is anticipated, attempt assisted intubation as in the purple patient. If
difficulty is anticipated, obtain expert assistance for further management if time permits. If not, needle or surgical cricothyroidotomy may be needed.

Figure 213-3 Jaw thrust. Rotate mandible forward with index fingers.
Arrow indicates motion to bring soft tissues forward to relieve airway
obstruction.

213 TRACHEAL INTUBATION

1459

Laryngeal opening
Nares
Hypopharynx
Trachea
Cricoid cartilage

Oral
pharynx
Uvula

Tongue

Figure 213-4 Anatomic landmarks of the head and neck.

Epiglottis
Vallecula

Vocal cords
Esophagus

STANDARD OROTRACHEAL INTUBATION

Preparation
Lack of proper preparation is another common reason for failure to
intubate. If the airway risk is purple or blue, auxiliary techniques
should be strongly considered. However, if the patient is classified
in the pink group, attempt standard orotracheal intubation. Prepare
for intubation using the mnemonic airway START. The airway
prefix distinguishes it from a similar mnemonic used for triage in
mass disasters.
SShade (classify the patient as pink, purple, or blue and select
the proper technique)
TTechnicians (respiratory technician and cricoid pressure
technician)
AAssemble (ensure all the equipment and drugs are
prepared)
RRespiration (preoxygenate with at least eight vital capacity
breaths. If time permits, and the patient is breathing spontaneously, 5 minutes of preoxygenation provides 5 minutes of
protection)
TTilt (ensure both the patient and the practitioner are properly positioned)

Route to
trachea

Arytenoid cartilage
Visualization
of cords
via pharynx

view is needed, the practitioner should bend at the knees and not
at the waist.
Intubation
The paraglossal technique has supplanted older methods of intubation. It is easier to learn, has a higher success rate, and uses the same
technique regardless of whether a curved or straight blade is used. I
have nicknamed the method the Diamond Technique, based on
the four Ds of the steps used to intubate:
DentalAlways hold the laryngoscope in the left hand. Place
the flange of the blade against the right molars with no tongue
intervening.
DeepSweep the tongue centrally and insert the blade to the
hilt or until resistance is met in the esophagus. If the patient is
in the sniffing position, this is usually easy. If the patient cannot
be moved safely into the sniffing position, follow the contour

Technique
The cricoid pressure technician should initiate cricoid pressure using
the Sellick maneuver as soon as the respiratory therapist begins
bagging. This will reduce stomach insufflation and the risk for vomiting. The cricoid pressure technician also watches the oxygen saturation of the patient and announces saturations below 90% to the
practitioner. In addition, this technician holds the endotracheal
tube and passes it to the practitioner so the practitioner can focus
uninterrupted on the intubating view.
Tilt or position of the patient and the practitioner is often
overlooked, but this is probably the most critical component of successful intubation. If the patient is not suspected of having neck
problems that could be worsened by movement, place the patient
in the sniffing position with the neck flexed and the head extended
backward (Fig. 213-5). The neck may be flexed by raising the head
several inches using a folded towel or firm pillow. It is important to
remember that the padding should be placed under the head and
not between the shoulders (see Fig. 213-4).
The position of the practitioner is even more important. The
most common problem is having an angle of view that is too high
to visualize the anatomy, which is caused by being both too close to
and too high above the patient. Crowded conditions at the head of
the bed in most care settings compound this problem. Unfortunately,
the practitioner usually reacts by bending forward at the waist,
which serves only to worsen the angle of view. Raise the bed and
move it a full 2 feet or more forward if possible. If a lower angle of

B
Figure 213-5 Proper head position is important for successful endotracheal intubation. Axes of the mouth, pharynx, and larynx need to be aligned.
A, Divergent axes. B, Axes in line, or sniffing position.

1460

HOSPITALIST

of the base of the tongue to reach the esophagus. Place the

blade deeply and in the esophagus on purpose. In this position,
the location of the tip of the blade is known and, more important,
so is the location of the airway: shallow and superior to the
blade tip.
DirectOnce the blade is in the esophagus, lift the handle
upward and forward (see Fig. 213-2), using the same technique
as in the older methods of intubation.
DepartFrom this position, withdraw the blade while monitoring the view. Most of the time, there will be a slight sensation of
give when the blade clears the esophagus, and a good intubating
view is obtained.
From this position, the practitioner requests the tube from the
cricoid pressure technician. Once received, the practitioner inserts
it with the right hand guiding the tip down against the right buccal
mucosa to avoid obstructing the intubating view (Fig. 213-6). A
common mistake is to try to slide the tube straight down the center.
This obstructs the view and increases the probability of accidental
esophageal intubation. The endotracheal tube is advanced until the
tip is at least 2 to 3cm beyond the vocal cords.
Rarely, the tip of the epiglottis is encountered. If this is the case,
lift the epiglottis with the blade tip. Using the right hand, after
handing the tube back to the technician, replace the pressure on
the cricoid cartilage that is being applied by the pressure technician.
Manipulate the trachea to obtain a good view (commonly, the
cricoid pressure technician will use too much pressure). When a

Figure 213-7 Auscultation points for confirmation of placement are

over the stomach (should be lack of sound) and the axillae. The same locations should be used to auscultate in the adult.

good view is obtained, have the cricoid pressure technician replace

the same amount of pressure to maintain a constant view. The
technician then hands the endotracheal tube back to the practitioner, who intubates the trachea as described previously. The tube
insertion depth can be approximated by the Chula formula: 4cm +
(patient height in inches/4). In most patients, this will be between
21 to 23 cm. Inflate the balloon according to manufacturer directions. Most balloons take 10mL of air.
Confirm Placement
Listen at the stomach to assess for an esophageal intubation, and
then listen in each axilla to assess for equal breath sounds. Listening
over the anterior chest is not as accurate as listening in the axillae
for determining proper tube placement (Fig. 213-7). Asymmetric
breath sounds suggests that the mainstem bronchus was intubated
typically, the right mainstem bronchus because it is more vertical
than the left mainstem bronchus.
Next, use a secondary device to ensure proper placement. The
devices available include bulb-type and syringe-type esophageal
detector devices or carbon dioxide colorimetric devices. These
devices are attached to the endotracheal tube after intubation. The
bulb device is squeezed shut before being placed on the tube. If the
bulb reinflates, the tube is in the proper location. One way to
remember this is reinflate means youre great. If a syringe device
is used, aspiration of more than 30mL of air indicates proper tube
placement. Colorimetric devices, which change from yellow to
purple with an elevated carbon dioxide level, are also useful. These
end-tidal carbon dioxide detectors are placed between the tube and
the bag-valve device after intubation: the detectors will change from
purple to yellow if the tube is in the proper location. An easy way
to remember the colors is yellow, yellow in the bellow. Carbon
dioxide capnographic devices should show adequate respiratory
waveforms. These forms are characterized by three phases: baseline,
rapid upstroke, and long alveolar plateau, similar to a small r
written in longhand.

B
Figure 213-6 Insertion of tube with laryngoscope in place. A, Insert the
tube with the tip initially against the right buccal mucosa so that a clear view
of the vocal cords can be maintained at all times. As it advances, watch the
tube pass through the cords. B, The tube is correctly placed when the tip is
2 to 3cm beyond the vocal cords.

Figure 213-8 Secure the tube to minimize patient discomfort while

maintaining correct positioning. Consider a bite block.

213 TRACHEAL INTUBATION

Secure
Secure the tube with umbilical tape or a commercial device made
for that purpose (Fig. 213-8). Avoid using tape or tincture of benzoin
on the face because facial irritation can cause at least temporary skin
changes. Consider inserting a bite block if the patient might bite the
tube. Insert a nasogastric or orogastric tube. Use chemical restraints
with appropriate monitoring to prevent tube removal. Finally, take
a chest radiograph to ensure proper depth and placement. The ideal
location is to have the tube 2 to 3cm above the carina.

Rapid-Sequence Intubation
Rapid-sequence intubation is an important technique to assist intubation in patients who are combative. It prevents laryngospasm and
can have other therapeutic benefits. The prime candidate has been
the cant intubate, cant ventilate patient, but in actual practice
this is rare. Airway assessment before the procedure should detect
patients at risk for this problem, and often alternative methods can
be used. Rarely, this may occur without warning, so an intermediate
airway, such as a LMA or Combitube, as well as a cricothyroidotomy
kit, needs to be readily available. There are many medications from
which to choose and the topic can be complex. Here, only the most
common technique is explained, and this will be suitable for patients
without suspected bronchospasm or increased intracranial pressure.
Choose the paralytic agent. Succinylcholine 1.5mg/kg is the first
choice unless contraindicated. Contraindications are conditions
in which hyperkalemia may be worsened, where there is concern
that increased intracranial pressure or intraocular pressure may
worsen the patients condition, or there is a risk of malignant
hyperthermia such as the following:
End-stage renal disease with missed dialysis
Rhabdomyolysis (e.g., patients found down for a long time)
Muscular dystrophy of any type
History of spinal cord injuries
Open globe injury (of controversial significance)
Conditions under which there may be increased intracranial
pressure
History of a recent cerebrovascular accident
Burns of greater than 10% body surface area more than 24
hours old but incompletely healed
Patients with crush injuries more than 24 hours old
Family history of an anesthetic reaction
If succinylcholine is contraindicated, rocuronium 0.6 to 1mg/kg
is considered by many to be the best alternative. It has a rapid
onset of action, but paralysis lasts an average of 50 minutes,
placing it second to succinylcholine. However, if succinylcholine
is indicated, then a standard dose is 2 mg/kg intravenously. It
should not be given until other preparations are made.
Choose the sedative agent. Etomidate (0.3 mg/kg intravenous
perfusion) is the most common choice because of its lack of
cardiovascular depression and versatility. Other agents include
ketamine 1 to 2mg/kg in bronchospasm, midazolam 0.2mg/kg,
or thiopental 3mg/kg in increased intracranial pressure. Each has
its benefits and drawbacks, which should be studied before use.
Choose the adjuncts. Although not indicated in all cases, lidocaine 1.5 mg/kg is considered useful in patients with bronchospasm or concerns for increased intracranial pressure. Atropine
should be administered to children younger than 10 years of age
at 0.02 mg/kg (minimum 0.1 mg, maximum 1 mg) to inhibit
reflex bradycardia before the use of succinylcholine. Atropine
should be considered for any adult who is receiving either ketamine or a second dose of succinylcholine during the intubation
or reintubation procedure to reduce complications.
Three minutes before intubation, give adjuncts.
Two minutes before intubation, give a priming dose (10% of the
dose drawn up in the syringe) of succinylcholine (if this medication is to be used for paralysis).

1461

One minute before intubation, give the paralytic agent (succinylcholine or rocuronium), followed immediately by the sedative
(etomidate, midazolam, or thiopental). Begin giving the patient
eight vital capacity breaths.
Assess for adequate paralysis by gently stroking the eyelashes. If
there is no response, proceed with intubation as described in
previous sections.

NASOTRACHEAL INTUBATION
Nasotracheal intubation generally requires the patient to be breathing spontaneously, and has the complications of nasal bleeding and
sinusitis. It is of limited usefulness except in cases where awake
intubation is required. This technique is relatively contraindicated
in the combative patient and in those patients with a coagulopathy
or bleeding diathesis. It is important to examine the facial anatomy
and nares for distortion, trauma, or other contraindications. If no
contraindications are noted, use the side with the larger passage. If
they are equal, use the right side because this helps reduce trauma
from the tube bevel. Use a 6.5-mm tube or smaller, if anatomically
indicated.

Preparation
Most nasotracheal intubation failures are the result of inadequate
preparation.
Get an assistant.
Explain the procedure to the patient. This is the most important
step.
Place the patient in the standard sniffing position, as described
previously.
Determine if nasal vasoconstriction is safe. If the patient appears
to be at risk for limited perfusion to the nasal area from either
local or systemic disease, avoid the use of a vasoconstrictor.
Prepare the nasopharyngeal path. Place 15mL of 2% lidocaine
with epinephrine (or plain lidocaine, if vasoconstriction is contraindicated) in a Toomey syringe.
Have one assistant keep the syringe upright to prevent spillage,
and connect the Toomey syringe to a small Foley catheter. A red
Robinson catheter is preferred.
While an assistant continues to hold the catheter upright, lubricate the distal catheter with a water-soluble lubricant.
With the free hand, apply cricoid pressure. This facilitates entry
of the catheter into the airway. Insert the catheter through the
nose to the level of the vocal cords. This is approximately twice
the distance from the front of the lips to the tragus of the ear.
Ideally, the patient will cough, indicating vocal cord
stimulation.
Have the assistant turn the syringe upright and administer about
5mL of the solution while the patient coughs, which helps disperse the solution.
Withdraw the catheter, administering another 5mL of the solution as the catheter is removed.
Administer the last 5mL at Kiesselbachs plexus in the anterior
nasal passage of the septum. Allow the solution to work while
lubricating the endotracheal tube and checking the balloon.

Two-Handed Nasotracheal Intubation

Technique
Standing at the side of the patient, insert the tube so the leading
edge of the bevel is away from the septum. If the left nostril is
used, the tube will be initially inserted with most of it positioned
above the face and scalp, and then rotated 180 degrees once the
turbinates are passed.
Once the tube is about halfway in, apply cricoid pressure with
the nondominant hand. Remember that unlike in training

1462

HOSPITALIST

Assistants hand

Magill
forceps
Do not
grasp cuff
with forceps

Figure 213-9 Nasotracheal intubation using a laryngoscope and Magill

forceps. The forceps are not used to pull the tube; rather, they serve to
guide the tip of the tube through the vocal cords while an assistant advances
the tube. The cuff is frequently damaged if it is grasped. (Modified from
Roberts JR, Hedges JR [eds]: Clinical Procedures in Emergency Medicine, 3rd ed.
Philadelphia, WB Saunders, 1998.)

models, the trachea is a mobile structure. Use this advantage to

move the trachea to assist placing the tube.
Lean forward and listen for breath sounds through the end of
the tube, adjusting both the tube and the trachea to create
maximum breath sounds. Once resistance is felt at the vocal cord
opening, await inspiration and then guide the tube past the vocal
cords. This is often easily felt with the hand manipulating the
trachea.
Pass the tube 26 to 28cm in an adult, depending on the size of
the patient.
Check and secure the tube in the standard fashion (see Fig.
213-8).
Direct visualization can also be used for nasotracheal intubation.
With the patient supine, use the laryngoscope in the same
manner as for standard intubation. While visualizing the cords,
use the Magill forceps to grasp the tube already inserted through
the nasopharynx and pass it through the cords (Fig. 213-9).
Avoid tearing the cuff when grasping the tube with forceps.

POSTPROCEDURE PATIENT CARE

Order daily chest radiographs to verify tube placement.
The respiratory services department of the hospital usually supplies the ventilator, tape, and other equipment as well as providing care; however, the clinician is ultimately responsible.
Check the patient and the respiratory setup frequently. Carbon
dioxide detectors and whistles can be used to confirm expiratory
efforts.

COMPLICATIONS
Short-term laryngeal edema: Sore throat occurs in almost every
patient after extubation (repeated attempts at intubation by
unskilled personnel may cause enough edema to preclude intubation by highly skilled clinicians).
Trauma
Broken teeth
Oral lacerations or ulcerations (lip, tongue, pharynx, esophagus, or trachea)

Bleeding, hematoma, or abscess formation as a result of

trauma
Avulsion of arytenoid cartilage
Hypoxia resulting from
Long duration of procedure
Esophageal intubation (most commonly results from not visualizing the vocal cords)
Intubation of a bronchus
Failure to recognize esophageal or bronchial intubation
Pneumothorax
Failure to secure the placement
Failure to recognize misplacement of the tube
Aspiration of vomited material, especially in unconscious or
semiconscious patient
Laryngospasm
Hypertension/hypotension
Bradycardia
Tachycardia with or without arrhythmias
Sequelae of long-term endotracheal tube placement
Nosocomial infection
Pneumothorax
Corneal abrasions
Epistaxis
Sinusitis
Vocal cord damage or paralysis (left cord more frequently
involved than right)
Tracheomalacia and stenosis (occur more frequently in men;
are more common with older tubes that use higher cuff
pressures)
Tracheoesophageal fistula
Innominate artery erosion by endotracheal cuff
Rarely are teeth broken with nasotracheal intubation.
However, acute epistaxis and nasal trauma can result. Pulmonary
infection can also be caused by nasal flora introduced through the
nasotracheal tube.

NOTE:

CPT/BILLING CODE
31500

Intubation, endotracheal; emergency procedure

ICD-9-CM DIAGNOSTIC CODES

276.2
276.3
276.4
427.5
428.1
491.20
491.21
492.8
493.01
493.91
518.5
518.81
518.82
518.83
780.01
785.50
785.51
785.52
785.59
786.09
799.02
799.1

Acidosis
Alkalosis
Acid-base mixed disorder
Cardiac or cardiorespiratory arrest
Pulmonary edema (left heart failure)
Chronic obstructive bronchitis, without exacerbation
Chronic
obstructive
bronchitis,
with
(acute)
exacerbation
Emphysema, NOS
Asthma, extrinsic with status asthmaticus
Asthma, unspecified with status asthmaticus
Pulmonary insufficiency following trauma and surgery
Respiratory failure, NOS
Respiratory distress, insufficiency or syndrome; acute
Respiratory failure, chronic
Coma
Shock, unspecified
Shock, cardiogenic
Shock, septic
Shock, hypovolemic or other
Respiratory distress or insufficiency, other, including
hypercapnia
Hypoxemia
Respiratory arrest or cardiorespiratory failure

ACKNOWLEDGMENT
The editors wish to recognize the many contributions by Len Scar
pinato, DO, to this chapter in the previous two editions of this text.

SUPPLIERS
(See contact information online at www.expertconsult.com.)
Cook Medical
Mallinckrodt, Inc.
Rusch
Sims Portex, Inc.

BIBLIOGRAPHY
American Heart Association: Advanced Cardiovascular Life Support Provider Manual. Dallas, American Heart Association, 2006.
Butler J, Sen A: Best evidence topic report: Cricoid pressure in emergency
rapid sequence intubation. Emerg Med J 22:815816, 2005.

213 TRACHEAL INTUBATION

1463

Ellis DY, Harris T, Zideman D: Cricoid pressure in emergency department

rapid sequence tracheal intubations: A risk-benefit analysis. Ann Emerg
Med 50:653665, 2007.
Hagberg CA (ed): Manual of Difficult Airway Management. Philadelphia,
Churchill Livingstone, 2000.
Kopman AF, Zhaku B, Lai KS: The intubating dose of succinylcholine: the
effect of decreasing doses on recovery time. Anesthesiology 99:10501054,
2003.
Marx JA, Hockberger RS, Walls RM (eds): Rosens Emergency Medicine:
Concepts and Clinical Practice, 6th ed. Philadelphia, Mosby, 2006.
Naguib M, Samarkandi AH, El-Din ME, et al: The dose of succinylcholine
required for excellent endotracheal intubating conditions. Anesth Analg
102:151155, 2006.
Reichman EF, Simon RR (eds): Emergency Medicine Procedures. New York,
McGraw-Hill, 2004.
Tintinalli, JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine:
A Comprehensive Study Guide, 6th ed. New York, McGraw-Hill,
2004.
Walls RM, Murphy MF, Luten RC, Schneider RE (eds): Manual of Emergency Airway Management, 2nd ed. Philadelphia, Lippincott Williams
& Wilkins, 2004.