- 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
- Evaluate: 3-3-2
- Mallampati Score
- Neck mobility
- Restricted opening
- 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
- Rocuronium (Zemuron) IV/IO; max 100 mg
- 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)
- Etomidate 15 mg or 7.5 mL
Ketamine Dosing Chart
(use in patients with hypotension and reactive airway disease)
- 2 mg/kg IV/IO, Max dose 200 mg
Succinycoline Dosing Chart
- Succinycoline 75 mg or 3.75 mL
- Succinycoline 150 mg or 7.5 mL
- Succinycoline 150 mg or 7.5 mL
- 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.
- 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).