Acute Care 3:
Rapid Sequence Intubation Algorithm/Rescue Airways
| 1. Prepare: | Equipment, meds, team, patient (basic airway management, positioning) |
| 2. Preoxygenate: | 100% O2, 3 to 5 minutes |
| 3. Premedicate: | Atropine
(0.02 mg/kg IV; PEDS minimum 0.1 mg in
children < 8 years) Lidocaine 1.5 mg/kg IV (head injury, asthma) |
| 4. Push the sedative: | Use
one: Etomidate 0.3 mg/kg IV: Use with caution in septic shock. Consider alternative sedation or supplemental corticosteroids Midazolam 0.1 mg/kg IV (adults) PEDS: 0.3 mg/kg IV: Suggested maximum single dose 10 mg; reduce dose or consider alternative in hypotension or elderly Ketamine 1 to 2 mg/kg IV (bronchodilator) Raises intracranial pressure; avoid in head injury. |
| 5. Paralyze: | Use
one: Succinylcholine 2 mg/kg IV Avoid in hyperkalemia, neuromuscular disease, or ocular trauma Vecuronium 0.1 mg/kg IV OR Rocuronium 1 mg/kg IV Wait for relaxation (45-60 sec). Do not bag unless hypoxic. |
| 6. Position airway: | Head/neck position; laryngeal manipulation, BURP, cricoid pressure as needed |
| 7. Pass the tube: | Maintain in-line cervical immobilization in head/neck trauma |
| 8. Patent airway assessment: | Use esophageal intubation detector, check breath sounds, CO2 detector |
| 9. Post-intubation plan: | Drugs and dosages depend on medications
used during intubation Sedation: Midazolam 0.05 to 0.3 mg/kg IV. Suggested maximum single dose 10 mg; reduce dose or consider alternative in hypotension or elderly Paralysis: Vecuronium 0.1 mg/kg IV (if not used for intubation) Analgesia: Fentanyl 1 to 2 MICROgrams/kg IV
Morphine 0.05 to 0.15 mg/kg IV
Consider need for seizure prevention. |
Repeat as needed to maintain sedation, paralysis, and analgesia.
| Rescue airways may be needed when RSI fails or other methods of airway control are indicated. Some situations are listed below: |
| Method | Typical Application |
| Combitube™ | Upper
airway anatomy relatively intact Blind insertion The patient is obtunded Failed RSI—follow with sedation/analgesia Two sizes available: Combitube SA 37F (4
to 5 ½ feet)
Combitube 41F (5 feet and taller) |
| King Airway | Patient
condition same as Combitube Sizes 3, 4, and 5 available King LTS-D allows for passage of 18G suction catheter |
| Laryngeal Mask Airway |
Upper airway anatomy relatively intact |
| Intubating LMA | Good
in morbid obesity Does not require visualization of glottis Does not require neck motion Awake intubation with topical anesthesia is possible |
| Transtracheal Needle |
Severe laryngeal edema as in acute epiglottitis or severe allergic reaction with airway obstruction |
| Cricothyrotomy | Use
if failure of other methods PEDS: The patient is older than about 8 years May be first choice in facial trauma |
| Tracheotomy | Laryngeal
trauma with obstruction PEDS: Failure of other methods in children less than 8 years |