1. Prepare equipment and position patient as appropriate:
    1. Pre-intubation capnography is the standard of care when utilizing BVM to assist ventilations pre-RSI.
    2. Pre-oxygenate with 100% FiO2.
    3. Back–up plan: LMA, anesthesia, and/or surgical airway.
  2. For "Crash Airways" proceed to Step 6
    1. A patient with a GCS of 8 or less, a low oxygen saturation, Apnea or significant tachypnea and has not responded to basic methods of ventilation and oxygenation or if clinically indicated.
  3. Consider pre-medication as appropriate:
    1. Consider Atropine for patients < 1 year:  0.02 mg/Kg IVP (minimum dose 0.1 mg)
  4. Provide analgesia with Fentanyl: (see pain/sedation protocol)
  5. Induce unconsciousness with Etomidate 0.1-0.3 mg/Kg IVP or Ketamine 1-2 mg/kg IVP or versed 0.1-0.2 mg/kg.
  6. Induce paralysis with: **Ensure ventilation prior to paralysis.
    1. Rocuronium (Zemuron)
      1. 1 mg/Kg IVP (Up to a max dosage of 100mg) OR
    1. cisatracurium (Nimbex):
      1. < 12 years: 0.1 mg/Kg IVP
      2. > 12 years: 0.2 mg/Kg IVP

Consider risk of paralytics if:

  • Unable to bag-mask ventilate
  • Known difficult intubation.
  • Mediastinal mass
  • Other contraindications

ETT placement will be confirmed using CXR and continuous waveform capnography.


  1. Sedation, analgesia and neuromuscular blockade may be utilized as necessary to ensure a secure airway and for the comfort of the patient.
  2. Appropriate sized bag-valve-mask available for accidental extubation.
  3. Provide gastric decompression.
  4. Sedation/Analgesia: (see pain/sedation protocol)
    1. Midazolam (Versed) may be repeated as necessary based on clinical response
    2. Fentanyl may repeat as necessary based on clinical response
  5. Neuromuscular blockade for post-intubation paralysis with cisatracurium (Nimbex) or Rocuronium (Zemuron)

All intubated patients will have continuous waveform capnography post intubation.


  1. Hsiao AL, Baker MD. Childhood Resuscitation. Pediatric Emergency Medicine Secrets. Second ed. Mosby; Philadelphia, PA. 2008. pp. 9-19.
  2. Yamamoto LG. Emergency Airway Management – Rapid Sequence Intubation. Textbook of Pediatric Emergency Medicine. Fifth ed. Lippincott, Williams & Wilkins; New York, NY. 2006. pp. 81-92.