Protocol Status: PUBLISHED
Protocol:
Version: 2026.01
Effective Date:
Last Reviewed:
Medical Director Approval:
Clinical Note: This content reflects current GCEMS clinical guidelines as of the dates listed above. If content appears inconsistent with current policy, use the most recent approved guideline and notify leadership for correction.

Adult Airway: MFI/RSI

5.2 A & B

 

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

 

 

Unsuccessful?

 

  • See: Failed Airway Protocol

 

Successful?

 

  • 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

 

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).