Page 14 - 2026 SMOG

RAPID SEQUENCE INTUBATION
History Medications
• Airway compromise or inability to protect the • Induction Agents:
airway ˚ Ketamine 1–2mg/kg IV/IO
• Respiratory failure (Hypoxic, Hypercapnic) ˚ Etomidate 0.3mg/kg IV/IO
˚ >40% TBSA burns, severe sepsis, TBI with ˚ Propofol 1–2.5mg/kg IV/IO
AMS, etc.
˚
Midazolam 0.01–0.05mg/kg IV/IO
• Patient or crew safety • Paralytics
• Combative, prolonged in critically sick ˚ Rocuronium 1mg/kg IV/IO
Contraindications ˚ Vecuronium 0.1mg/kg IV/IO
˚
Succinylcholine 1.5mg/kg IV/IO
• High likelihood of failure (distorted anatomy) • Maintenance
• Penetrating neck trauma ˚ Ketamine 0.5–2mg/kg IVP or 0.5–2mg/kg
Procedure bolus then 13mg/kg/hr
• Make a plan, prepare the patient and equipment ˚ Propofol 5–75mcg/kg/min
Midazolam 0.01–0.1mg/kg/hr
• Conduct the seven “P” mnemonic (7Ps) below ˚ (Best when used with Fentanyl
• SALAD technique (suction-assisted 0.5–1mcg/kg/hr)
laryngoscopy and airway decontamination)
• Push Dose Epi
˚ Epinephrine (0.1mg/mL)
5–10mcg IV/IO
Prepare
• Suction: available, check for function
• Oxygen: Pre-Oxygenation + Apneic Oxygenation
• Airways: ETT, SGA (iGel, King, etc.), Cricothyrotomy
• Pharmacology: Induction, Paralysis, Post-intubation Sedation
• Monitor: BP, HR, RR, SpO %, EtCO capnography, 4-lead
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• Equipment: Bougie, Laryngoscope, Video Laryngoscope, Cric Kit
• Evaluate Cricothyrotomy landmarks and assess procedural difficulty
Pre-Oxygen
• Preoxygenate/Denitrogenate ≥3min or 8 Vital Capacity Breaths with 15 LPM NRB or
BVM + PEEP, and NC 4–6 LPM, Oxygenated ≥90% if able
Positioning
• 30° head-up for pre-oxygenation, ear-to-sternal notch for intubation, C-spine consideration
Pretreat
• 3–5min prior to sedative/paralytic
• Resuscitate with IVF or blood products. Consider push-dose pressors (Epi) to ensure SBP >100
• Consider Fentanyl 0.5–1mcg/kg slow IVP to prevent hypertension in head injury, cardiac ischemia, or
aortic dissection.
Sedate/Paralyze
• Push sedative first before paralytic push
• Apneic oxygenate (utilize BVM if SpO falls below 90%)
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• Monitor SpO and EtCO ; wait for adequate paralysis
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Pass Tube
• SALAD
• Visualize the cords, pass the tube, inflate the bulb, and begin bagging
Post-Tube Management
• Verify tube placement with EtCO waveform capnography and secure the tube
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• Place the patient on post-intubation maintenance sedation
6 • GENERAL