Adult Airway: MFI/RSI

5.2 A & B



  • Age 12 or greater
  • Trauma with GCS 9 with gag reflex
  • Trauma with significant facial trauma and poor airway control
  • Closed head injury or major stroke with unconsciousness
  • Acute burn with airway involvement and inevitable airway loss
  • Respiratory exhaustion such as severe asthma, CHF or COPD with hypoxia
  • Overdose with AMS where loss of airway is inevitable


Difficult Laryngoscopy:

  • Look
  • Evaluate: 3-3-2
  • Mallampati Score
  • Obstruction
  • Neck mobility


Difficult BIAD:

  • Restricted opening
  • Obstruction
  • Distorted airway
  • Stiff lungs or c-spine



  • Age Less than 12
  • Difficulty ventilating patients with BVM
  • Anticipated difficult intubation based on physical exam of airway structures or airway history.


A minimum of two Paramedics on scene prior to sedation


  • Initiate apneic oxygenation
  • Place at 30⁰ - 45⁰ angle
  • Monitor O2 sat with pulse oximetry
  • Ensure functioning IV access
  • Prepare Equipment For Intubation, manage hypotension
  • Monitor heart rhythm with EKG
  • Etomidate (Amidate) IV/IO or Ketamine 2 mg/kg IV/IO max dose 200 mg; see dosing chart.
  • Continue apneic oxygenation with 15 LPM Oxygen via nasal cannula under BVM/CPAP to achieve SPO2 of 93%



  • Administer Succinylcholine (Anectine) IV/IO; max 150 mg
  • OR
  • Rocuronium (Zemuron) IV/IO; max 100 mg
  • Intubate trachea




  • Intubate trachea


  • Direct visualization of ETT through vocal cords
  • Continuous wave-form capnography
  • Assess lung and epigastric sounds



Etomidate Dosing Chart

(use in patients with significant hypertension)


  • ≤ 100 lbs or  ≤ 45 kg
    • Etomidate 15 mg or  7.5 mL
  • 100-200 lbs. or 45-91 kg
    • Etomidate 20 mg or 10 mL
  • ≥ 200 lbs. or  ≥ 91 kg
    • Etomidate 30 mg or 15 cc


Ketamine Dosing Chart

(use in patients with hypotension and reactive airway disease)


    • 2 mg/kg IV/IO, Max dose 200 mg


Succinycoline Dosing Chart


  • ≤ 100 lbs or  ≤ 45 kg
    • Succinycoline 75 mg or  3.75 mL


  • 100-200 lbs. or 45-91 kg
    • Succinycoline 150 mg or 7.5 mL


  • ≥ 200 lbs. or  ≥ 91 kg
    • Succinycoline 150 mg or 7.5 mL


Rocuronium Dosing:


  • 0.6 mg/kg IV/IO, Max dose 100 mg



  • If dangerously combative and in need of advanced airway, see COG 8.4 Behavioral Emergencies for IM Ketamine Dosing.
  • Intubation equipment includes: intubation kit, Bougie®, BVM, suction, BIAD, waveform capnography.
  • Succinycoline:
    • Contraindications include: Known renal failure patients with missed dialysis, known hyperkalemia, known neuromuscular disease:(myasthenia gravis, amyotrophic lateral sclerosis, muscular dystrophy), significant burns greater than 4 days old, Guillain-Barre syndrome, patient or family history of malignant hyperthermia. As a result these patients may not undergo RSI.
  • Patients with hypoxia and/or hypotension are at risk of cardiac arrest when a sedative and paralytic medication are administered. Hypoxia and hypotension require resuscitation and correction prior to use of these combined agents.
  • All appropriate measures must be taken to attempt to increase O2 saturation to greater than or equal to 93% prior to intubation.
  • MFI should be utilized for patients with an immediate airway management need but by rendering apneic (paralytics) could be catastrophic for the patient.
  • First pass attempt with video laryngoscopy is strongly encouraged.
  • There is a possibility of larynogspasm with high dose Ketamine administration. Consider the Larson's maneuver for management.
  • Bradycardia after tube placement is a strong predictor of a misplaced endotracheal tube (ETT).
  • Capnography: Is required for all advanced airway devices.
    • Should BIAD be confirmed with capnometry by first responder immediately switch to capnography upon arrival.
    • If waveform capnography loss (flatline) remove advanced airway and refer to Failed Airway Protocol.
    • If waveform capnography is replaced by a dashed line, immediately visualize correct placement of ETT. Once ETT is visualized and confirmed, make necessary equipment adjustments.
  • An airway evaluation form must be completed on every patient who receives drug assisted intubation (RSI).