Indications:

 

• 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

 

Contraindications:

 

• 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 20⁰ - 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.
• if no Etomidate, give (Midazolam) Versed 0.1 mg/kg IV/IO; max dose 8 mg
• Continue apneic oxygenation with 15 LPM Oxygen via nasal cannula under BVM/CPAP to achieve SPO2 of ≥ 93%

MFI

 

• Intubate trachea

 

RSI

 

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

 

Unsuccessful?

 

• See: Failed Airway Protocol

 

Successful?

 

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

• • See Post Airway Management

 

 

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

 

PEARLS:

 

• 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 confirmation signature must be obtained on every patient who receives drug assisted intubation (RSI).