Rapid Sequence Intubation




  • Age greater than or equal to 12
  • 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



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


Difficult BIAD:


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




  • Significant burns greather than 4 days old
  • Known neuromuscular disease such as myasthenia gravis, amyotrophic lateral sclerosis, muscular dystrophy
  • Guillain-Barre syndrome
  • Chronic renal failure patients who have not had hemodialysis within the past 24 hours
  • Known hyperkalemia
  • Age less than 12
  • Patient or family history of malignant hyperthermia


A minimum of two paramedics on scene: a minimum of one being RSI qualified


  • Pre-oxygenate with 100% Oxygen via BVM or CPAP if possible



  • Place at 30⁰ - 45⁰ angle


  • Monitor O2 sat with pulse oximetry



  • Monitor heart rhythm with EKG




  • Apply cricoid pressure




Successful ?


  • Yes


  • No



Successful ?


  • Yes



  • Notify receiving facility or contact Medical Control




  • Etomidate is preferred over Ketamine for trauma patients.
  • Ketamine can cause a heightened sympathetic response that will increase heart rate and blood pressure.
  • Intubation equipment includes: intubation kit, bougie, BVM, suction, RSI medications, BIAD, waveform capnography.
  • All appropriate measures must be taken to attempt to increase O2 saturation to greater than or equal to 94 % prior to intubation.
  • Do not use CPAP on the trauma patient.
  • Waveform capnography and pulse oximetry must be utilized for a minimum of 5 minutes after tube placement prior to the administration of Vecuronium (Norcuron) and is required for intubation verification and ongoing patient monitoring.
  • Bradycardia after tube placement is a strong predictor of a misplaced endotracheal tube (ETT).
  • An airway confirmation signature must be obtained in the ePCR.