- Prepare equipment and position patient as appropriate:
- Pre-intubation capnography is the standard of care when utilizing BVM to assist ventilations pre-RSI.
- Pre-oxygenate with 100% FiO2.
- Back–up plan: LMA, anesthesia, and/or surgical airway.
- For "Crash Airways" proceed to Step 6
- 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.
- Consider pre-medication as appropriate:
- Consider Atropine for patients < 1 year: 0.02 mg/Kg IVP (minimum dose 0.1 mg)
- Provide analgesia with Fentanyl: (see pain/sedation protocol)
- 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.
- Induce paralysis with: **Ensure ventilation prior to paralysis.
- Rocuronium (Zemuron)
- 1 mg/Kg IVP (Up to a max dosage of 100mg) OR
- cisatracurium (Nimbex):
- < 12 years: 0.1 mg/Kg IVP
- > 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.
- Sedation, analgesia and neuromuscular blockade may be utilized as necessary to ensure a secure airway and for the comfort of the patient.
- Appropriate sized bag-valve-mask available for accidental extubation.
- Provide gastric decompression.
- Sedation/Analgesia: (see pain/sedation protocol)
- Midazolam (Versed) may be repeated as necessary based on clinical response
- Fentanyl may repeat as necessary based on clinical response
- Neuromuscular blockade for post-intubation paralysis with cisatracurium (Nimbex) or Rocuronium (Zemuron)
All intubated patients will have continuous waveform capnography post intubation.
- Hsiao AL, Baker MD. Childhood Resuscitation. Pediatric Emergency Medicine Secrets. Second ed. Mosby; Philadelphia, PA. 2008. pp. 9-19.
- 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.