This document provides guidelines for endotracheal intubation using rapid sequence intubation (RSI). It outlines indications for RSI including respiratory arrest and compromised airways. It also lists contraindications and complications. The guidelines describe assessing for a difficult airway, preparing equipment and the patient, pre-oxygenating, pre-treating with medications, inducing paralysis, intubating, confirming tube placement, and post-intubation management. The goal is to control the airway while minimizing risks like aspiration, using the appropriate medications, techniques, equipment, and monitoring to intubate safely and effectively.

2. Level: Specially Trained EMT-P, RN

3. Indications:
A critical need for airway control exists, such as:
Any patient in respiratory arrest who have a gag reflex or are
clenched.
Patients with severe head and facial injuries.
Combative patients with compromised airways.
Patients with depressed LOC.
Patients with hypoxia refractory to oxygen (CPAP or Supplemental
Oxygen)
Any time risk for potential/actual airway compromise is suspected
such as acute burn injury.
Uncontrolled seizure activity (to provide airway control).
Status asthmaticus nearing respiratory arrest.

4. Relative Contraindications:
Patients in whom cricothyroidotomy would be difficult or impossible
(SHORT).
Massive neck swelling/injury.
Patients who would be difficult or impossible to intubate/ventilate
after paralysis.
 LEMON
 MOANS
 RODS
 SHORT
Acute epiglottitis.
Upper airway obstruction.
Known hypersensitivity to the drugs.
Note: The benefit of obtaining airway control must always be weighed
against the risk of complications in these patients.

5. COMPLICATIONS ASSOCIATED WITH INTUBATION
Increased intragastric pressure (emesis).
 Bradycardia/asystole (especially in children less than 1 yr not premedicated
with Atropine.)
 Malignant hyperthermia.
 Prolonged apnea.
 Inability to intubate/ventilate after paralytic administration.
 Hypotension.
 Aspiration.
 Dysrhythmias.
 Fasciculations.
 Histamine flush
 Tachycardia.
 Hyperkalemia.
 Inability to recognize decreased neurologic status.
 Bronchospasm

6. USE THE FOLLOWING TO DETERMINE DIFFICULT AIRWAY:
LEMON (Predicts difficult laryngoscopy).
MOANS (Predicts difficult mask ventilation).
RODS (Predicts difficult EGD).
SHORT (Predicts difficult cricothyrotomy).

7. LEMON (Difficult Laryngoscopy)
Look externally
Evaluate 3 – 3 – 2 rule
Mallampati
Obstruction/Obesity
Neck mobility

8. MOANS (Difficult Mask Vent)
Mask Seal
Obese
Aged (> 55 years old)
No teeth
Stiff (increased ventilatory pressures, e.g. asthma, COPD,
ARDS,term pregnancy)

9. RODS (Difficult EGD)
Restricted mouth opening
Obese
Distorted airway
Stiff as in MOANS

10. SHORT (Difficult Cricothyrotomy)
Surgery (previous)
Hematoma
Obese
Radiation
Tumor

11. Preparation
Assemble necessary equipment:
 Suction
 BVM with correct sized mask
 Working suction equipment
 Appropriate sized ET tubes
 Working laryngoscope
 Appropriate drugs drawn up in syringes
Pulse oximeter
 End-tidal CO2 monitoring device

12. Preparation cont.
 Assess patient for possible difficult intubation via LEMON, MOANS,
RODS, and SHORT.
 If there is a potential for a difficult airway, go to the Difficult
Airway Algorithm PAGE 488.
 Position patient properly in sniffing position or use in-line
stabilization if indicated.
 Assure at least one secure well running IV line.
 Connect patient to cardiac monitor and pulse oximeter.
 Assign specific duties to personnel on scene (i.e., assistance with
bagging, pushing of medications.)

13. Pre-Oxygenation
Place patient on continuous oxygen via nasal cannula at 6 lpm.
Once the patient is sedated and/or paralyzed, increase the flow
rate to 15 lpm via nasal cannula. Continue nasal cannula
oxygen throughout your intubation attempt while patient is
paralyzed.
Pre-oxygenate for three minutes via BVM (leave nasal cannula
in place until patient is intubated). This establishes oxygen
reservoir:
 Flushes out nitrogen
 Increases functional residual capacity of lung.
Once intubated, discontinue the nasal oxygen.
When adequately preoxygenated, a healthy 70 kg adult can
remain apneic for up to 6-8 minutes.
Children experience oxygen desaturation more quickly due to
their fast metabolism.
Obese patients experience oxygen desaturation more quickly
due to adipose tissue metabolizing faster.

14. Pre-Treatment
Pre-medicate as appropriate:
Lidocaine 1.5 mg/kg IVP 2 - 3 minutes before intubation:
For possible head injury patients, to mitigate increased intracranial
pressure (ICP) which may occur during intubation.
For patients with reactive airway disease, i.e. severe asthma.
For dysrhythmia control in patients at risk for ventricular
dysrhythmias.
NOTE: Lidocaine is contraindicated if there is known hypersensitivity
to the drug.

15. Pre-Treatment cont.
Fentanyl 3 mcg/kg (~200 mcg IV in average adult) Given as the last pre-
treatment drug. Administer over 30 – 60 seconds.
 Give as pre-medication for suspected head injury or increased
intracranial pressure.
DO NOT use on children under the age of 10.
Atropine 0.02mg/kg/IV (max 1 mg) – for children less than 12 months
receiving RSI.

16. Paralysis with Induction
Induce with ONE of the following:
Amidate (Etomidate) 0.3 mg/kg IV push for sedation.
NEVER REPEAT ETOMIDATE- NEVER REPEAT ETOMIDATE- NEVER REPEAT ETOMIDATE
Versed 0.10 - 0.15 mg/kg IVP for awake patients to achieve amnestic
effect. Pediatric dosage is 0.03 mg/kg.
Versed is contraindicated if the patient is hypotensive.
Alternative drug: Valium 2-10 mg IVP
Ketamine (Ketalar) 1 – 2 mg/kg IV (last resort 4 mg IM)
First choice for reactive airway disease.

17. Paralyze with one of the following:
Anectine (Succinylcholine - depolarizing) 1.5mg/kg IV over 10- 30 sec
NOTE: Onset 30 – 45 seconds.
Duration 4 – 10 minutes.
Rocuronium (Zemuron - non-depolarizing) 1mg/kg IV in adults
Children 0.6mg/kg IV
NOTE: Onset 45 – 60 seconds.
Duration: 20 – 90 minutes.

18. Succinylcholine

19. Use NON-Fasciculating agent (Rocuronium) on patients at
risk for or having problems related to:
Hyperkalemia (elevated potassium). Only if EKG Changes
show peaked T waves or wide QRS.
Penetrating eye injuries (do not use depolarizing blocker).
 History of malignant hyperthermia.
Unstable fractures (secondary to muscle fasciculation).

20. PARALYZE CONT.
Once paralytic has been given IV, discontinue bagging patient with
BVM and monitor pulse ox. It is not necessary to resume bagging
patient until patient is intubated (at which time you ventilate with
ambu-bag via the ET tube) or the oxygen saturation drops below 91%,
at which time you re-oxygenate before trying to intubate again.
Proper pre-oxygenation will allow you 6-8 minutes of allowable apnea
to intubate.
Perform controlled endotracheal intubation with in-line stabilization
if indicated.

21. TECHNIQUE OF ENDOTRACHEAL INTUBATION
Position the patient supine, open the airway.
Open mouth by separating the lips and pulling on upper
jaw with the index finger.
Hold laryngoscope in left hand, insert scope into mouth
with blade directed to right tonsil.
Once right tonsil is reached, sweep the blade to midline
keeping the tongue on the left. This brings epiglottis
into view. “DO NOT LOSE SIGHT OF IT!”
Advance the blade until it reaches the angle between
the base of the tongue and epiglottis (vallecular space).

22. TECHNIQUE OF ENDOTRACHEAL INTUBATION
CONT.
Lift the laryngoscope upwards and away from the nose –
towards the chest. This should bring the vocal cords into
view. It may be necessary for a colleague to press on the
trachea to improve the view of the larynx.
Place the ETT in the right hand, keeping the concave side
of the tube facing the right side of the mouth.
Insert the tube, just so the cuff has passed the vocal cords
and then inflate the cuff.
Using a stethoscope, listen for air entry at both apices
and both axillae to ensure correct placement.

23. Paralyze cont.
Confirm placement by auscultating for bilateral breath sounds,
checking oxygen saturations, and by checking for presence of end-
tidal carbon dioxide (ETCO2) or any three methods in the
confirmation protocol.
If intubation is unsuccessful, remove the tube and ventilate the
patient with 100% oxygen via a BVM until ready to attempt re-
intubation. You should be able to successfully use a BVM to oxygenate
the patient or successfully ventilate until the effects of the paralytic
are gone. Prepare to suction emesis.
Maintain cervical immobilization if necessary.
If after 1-2 repeat intubation attempts fail, go to failed airway
algorithm (4.34 SMART AIRWAY MANAGEMENT), which calls for using
and extra-glottic device or performing a cricothyrotomy. If an extra-
glottic device can be inserted or the patient’s oxygen saturation can
be maintained > 91% with an oral pharyngeal airway and BVM,
transport to hospital.
Only perform a cricothyrotomy if unable to ventilate and unable to
maintain pulse ox > 91%.

24. IF INADEQUATE RELAXATION IS PRESENT
ADMINISTER SECOND DOSE OF:
Anectine (Succinylcholine) 0.6mg/kg IV
Rocuronium is long acting, therefore second dose
not needed.

25. Post Intubation Management
Once intubation is completed and tube placement is confirmed, inflate
the cuff and continue to ventilate with 100% oxygen via BVM.
Secure ET tube in place.
Keep patient sedated with one of the following:
Versed 2 – 4 mg IV initial, then titrate 1 mg increments prn
Morphine 2-5 mg IV, then titrate 2 mg increments prn
Ketamine 0.25 to 0.5 mg/kg IV every 5 to 10 min prn
Continued paralysis will only be ordered by medical
control.

26. Post Intubation Management
Proper endotracheal tube placement must be documented by at
least three different methods. These include:
Presence of bilateral breath sounds.
Absence of breath sounds over the epigastrium.
Checking oxygen saturations.
Presence of condensation on the inside of the endotracheal
tube.
End-tidal carbon dioxide monitoring.
Use of an endotracheal esophageal detector (if available).
Visualizing the tube passing through the cords.
Bilateral, symmetrical expansion of the thorax.
At least three verification methods must be documented in the
medical record!

27. Considerations:
Once a neuromuscular blocking agent is given, you assume complete
responsibility for maintaining an adequate airway and ventilations.
Have your backup airway (King Airway) available to use if unable to
intubate.
Be prepared to perform a surgical airway if intubation cannot be
executed and ventilation with a BVM is not possible. (This will be rare.)
Continuously monitor oxygen saturations and end-tidal carbon dioxide.

28. FACILITATED INTUBATION
IS NOT RSI WITHOUT THE PARALYTIC!
THERE IS STILL A RISK OF THE PATIENT VOMITING BECAUSE THE
PATIENT IS SEDATED, NOT PARALYZED.