Indications:

 

• 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

 

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:

 

• 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

 

• If non-traumatic, provide apneic oxygenation with 15 LPM Oxygen via nasal cannula under BVM/CPAP

 

• Place at 30⁰ - 45⁰ angle

 

• Monitor O2 sat with pulse oximetry

 

• Ensure functioning IV access

 

• Monitor heart rhythm with EKG

 

• Etomidate (Amidate) IV/IO or Ketamine IV/IO

 

• RSI Dosing Chart

 

• Apply cricoid pressure

 

• After 1 min, administer Succinylcholine (Anectine) IV/IO; max 150 mg

 

• Intubate

 

• May repeat two times for a total of 3 attempts

 

Successful ?

 

• Yes

• • See: Post Airway Management

 

• No

 

• Place Supraglotic Device

 

Successful ?

 

• Yes

 

• • See: Post Airway Management

 

• Notify receiving facility or contact Medical Control

 

PEARLS:

 

• 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.