INTUBATION/RSI. PURPOSE: A. To facilitate secure, definitive control of the airway by endotracheal intubation in an expeditious and safe manner

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1 Manual: LifeLine Patient Care Protocols Section: Adult/Pediatrics Protocol #: AP1-009 Approval Date: 03/01/2018 Effective Date: 03/05/2018 Revision Due Date: 12/01/2018 INTUBATION/RSI PURPOSE: A. To facilitate secure, definitive control of the airway by endotracheal intubation in an expeditious and safe manner SCOPE A. This procedure shall only be performed by appropriately trained and EMS Medical Director-approved personnel from the agency for which the procedure is being performed. DEFINITIONS A. Rapid Sequence Intubation - a procedure that includes administering a paralytic and a sedative agent to a critically ill patient who is presumed to have a full stomach in order to facilitate rapid, successful, intubation. POLICY STATEMENTS A. Do not give paralytics if you are unable to bag-mask ventilate the patient. B. Never give paralytics without adjunct airway devices immediately available and ready for use C. All advanced airways must be used in conjunction with continuous waveform capnography (ETCO2) D. Relative contraindications: a. Facial/neck injuries which would preclude reasonable expectation of successful intubation b. Findings on airway assessment that raise concerns for difficulty of successful intubation c. Patients in full arrest prior to ROSC if BLS airway is achieving adequate chest rise and confirmed with continuous waveform capnography (ET CO2) GUIDELINES: 2) Initiate Airway Management protocol 3) Pre-oxygenate a. Attempt maximum pre-oxygenation with 100% NRB facemask, and, whenever possible, additional 15 LPM nasal cannula prong oxygenation. O2 via cannula should initially be set at 6-8 LPM (preferably 2-4 LPM in pediatric patients) in an awake patient (may go higher at provider discretion) then increased to maximum liter flow per minute when patient receives sedation. The cannula remains on during the entire intubation. b. Note that pediatric patients especially infants are higher risk of hypoxemia and may require BVM.

2 4) Prepare a. Prior to intubation the provider must ensure that: i. If suction is available, it must be easily accessible to the provider and functioning properly ii. There is properly functioning IV/IO access (ideally not on the same arm as the blood pressure cuff for an IV) iii. The patient is on pulse-oximetry (ideally not on the same arm as the blood pressure cuff) with continuous cardiac monitoring. Additionally, the monitor must have waveform capnography available to confirm the airway once placed. Cycle blood pressure reading for every 5 minutes. iv. The patient is being pre-oxygenated as above in section 2. v. Appropriate airway equipment is available, immediately accessible, and functioning properly (laryngoscope with functioning light source, king airway/lma AND- BVM must be available and immediately accessible, and cricothyrotomy kit immediately accessible. vi. Appropriate medications are available and the dosages are checked for the patient (see below) vii. Pre-intubation capnography is the standard of care when utilizing BVM to assist ventilations pre-rsi. Target EtCO2 = viii. ET tube sizes: 1. Adult: 7.5 to 8.0 cuffed a. May use smaller as needed in emergency situations 2. Pediatrics: a. Predicted size of uncuffed tube = (Age / 4) + 4 b. Cuffed tube is preferred and should be preferentially used over uncuffed tubes i. Exceptions are generally in the neonatal population c. Cuffed tube is 0.5 less than the calculated uncuffed tube size ix. Position patient 1. Prior to the initiation of RSI, the provider must optimize patient positioning to maximize the chance of first attempt success with intubation a. For trauma patients: c-collar open and in-line stabilization in a neutral position by holding the maxilla immobile bilaterally b. Non-trauma patient: head tilted back such that the face is parallel to the ceiling (i.e. place the patient in sniffing position: ear is lined up with the sternal notch). c. For pediatric patients: i. Use a shoulder roll for infants and toddlers when applicable

3 5) For Crash Airways (a patient with a GCS of 9 or less or an AVPU score of P or U, an oxygen saturation of less than 90%, a respiratory rate of less than 10/min or greater than 30/min and has not responded to basic methods of ventilation and oxygenation) proceed to Step 8 6) Pre-medicate as appropriate at least 3 minutes prior to intubation a. Consider atropine for patients < 1 year: 0.02 mg/kg IVP (minimum dose 0.1 mg) i. Maximum single dose of 1mg IVP 7) Induce unconsciousness, then paralyze a. Induction options include: a. Ketamine 1.5 mg/kg IV/IO and estimate the dosage using 150mg of ketamine ii. Pediatric maximum single dose 150 mg IV/IO iii. DO NOT use ketamine in patients with ACS or CVA iv. Consider using etomidate for patients with extremely elevated blood pressures (SPB > 220mmHg) b. Etomidate 0.3mg/Kg IV/IO and estimate the dosage using 30mg of etomidate ii. Use caution in patients who are hypotensive or in septic shock. These patients may more likely benefit from ketamine as an induction agent. b. Paralyze with rocuronium (Zemuron ) 1 mg/kg IV/IO and estimate the dosage using 150mg of rocuronium for an adult male or 100mg of rocuronium for an adult female. Alternatively, providers can use 1.5mg/kg IV/IO. 8) Place of airway (with proof of success) a. Apneic oxygenation with a nasal cannula at 15 lpm during airway placement. b. Airway placement i. Two attempts of oral intubation may be attempted ii. Place supraglottic airway if not intubated immediately iii. If airway is not secured, utilize OP/NP airway and BVM iv. If unable to ventilate, perform cricothyrotomy c. ETT placement will be confirmed using continuous waveform capnography and at least two other additional objective methods (auscultation, fogging in the ET CO2, chest rise) a. Continuous waveform capnography is the gold standard and takes precedence over the other measures listed above b. Auscultation of bilateral breath sounds and absence of breath sounds in the epigastrum is the second most preferable backup method when feasible.

4 9) Post-intubation/airway management a. Continue EtCO2 and pulse-oximetry monitoring b. Providers should be aware of the risk of right mainstem intubation and have the tube at an appropriate depth. Providers may opt to confirm proper positioning with a post-intubation stat chest radiograph whenever feasibly possible. However in an airway confirmed with continuous waveform capnography and two other objective methods that is at an appropriate depth based on age, tube size, and/or gender for adults, the provider should not significantly delay transport to definitive care in order to obtain a chest radiograph. c. Cycle vital signs for every 5 minutes d. Airway management via mechanical ventilator is the expectation for all patients with an artificial airway. Ventilator checks will be completed and documented at least every 15 minutes e. Appropriate sized bag-valve-mask available for accidental extubation. f. Provide ongoing sedation and pain control as needed: i. Ketamine 0.5mg to 1 mg/kg IV/IO every 5 to 10 minutes as needed 1. Provides both sedative and analgesic properties 2. DO NOT use in ACS or CVA ii. Midazolam 0.1 mg/kg IV/IO (do not use if SBP<100 in adult and SBP < 70 + (Age x2) in pediatrics) every 10 minutes as needed for sedation 1. Use as little versed a reasonably possible 2. Provides only sedation, there is no analgesic effect 3. Best used in conjunction with fentanyl to ensure concurrent pain control 4. Maximum single dose 5mg iii. Fentanyl 1 mcg/kg IV/IO every 5 minutes as needed for pain and/or sedation 1. Hold for SBP < 90mmHg in adult and SBP < 70 + (Age x2) in pediatrics 2. (optional) Provider can dose 100mcg every 3-5 minutes for adult patients 3. Pediatric Maximum single dose 50 mcg iv. Versed and Fentanyl immediately post-intubation 1. ADULT ONLY: If the provider chooses to administer both fentanyl and midazolam, ensure SBP is greater than 100mmHg and administer 100mcg of fentanyl IV and 2mg of versed IV, one time g. A gastric tube may be considered for stomach decompression if BVM ventilation occurred for more than 1-2 minutes if there are no contraindications i. The gastric tube should be connected to low intermittent suction.

5 h. Venous blood gases will be obtained 10 minutes after placing the patient on the ventilator whenever feasibly possible, however this should not take precedence over other critical tasks requiring the crews immediate attention. pco2 values are to be correlated with EtCO2 readings. Values are to be used to adjust ventilatory parameters to the best of the provider s ability based on the patient s suspected disease processes. Required Documentation: A. Document the procedure note for each attempt (an attempt is defined as the laryngoscope blade passing the teeth) including: time, glottic opening visualization grade, tube size, depth of insertion, adjuncts used, complications, securing device, lowest oxygen saturation during the procedure, and at least 3 methods of confirmation of ETT placement.