Protocol 2-044 - Airway: RSI

CMH EMS & MIH Protocols

EMD:

• No specific protocol.

EMR:

• Maintain airway and ventilate with 100% Oxygen for 5 minutes, if possible.
• Attempt to maintain SpO2 above 90% at all times.
• Consider nasal cannula at 15 LPM after sedation.
• Avoid BVM prior to Intubation if SpO2 above 90% to reduce gastric inflation.
• Attach Cardiac Monitor.

EMT:

• Ensure completion of applicable items above.
• Request a second ALS ambulance or supervisor, if possible.
• Assist ALS with Capnography.
• Ventilate rate and volume to maintain Capnography, if able:
• Head Trauma: 35-45 mmHg
• No Head Trauma: 35-40 mmHg
• Review RSI CONTRAINDICATIONS:
• Unable to ventilate with BVM.
• Severe facial or neck trauma.
• Possibility of failure of backup airways.
• Cricothyrotomy would be difficult or impossible.
• Acute epiglottitis.
• Press "PRINT" on the Cardiac Monitor after Intubation and at transfer to ER or LZ to record Capnography waveform.
• Maintain warmth of the paralyzed patient.

AEMT:

• Ensure completion of applicable items above.
• IV NS/LR.
• Consider LR 250 ml bolus.
• Consider second vascular access.

RN:

• Ensure completion of applicable items above.
• RSI is indicated for all patients with a pulse needing Intubation.
• Consult BLS crew members to ensure absence of contraindications.
• Consider IO NS/LR 250 ml bolus.
• Assign duties.

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• PREMEDICATE:
• Seizing: Refer to Protocol 2-792 - Seizure. Remember, paralysis will mask seizure activity.
• Hypotension Refer to Protocol 2-583 - Hypotension / Shock

• Adult:	Pediatric:
  Bradycardic: Atropine 0.5 mg IV/IO. Pain and/or Tachycardia: Consider Fentanyl 3 mcg/kg IV/IO/IN (max 300 mcg). Click "calculate" to get dose.	Atropine 0.02 mg/kg IV/IO (min 0.1 mg) (max 0.5 mg). Click "calculate" to get dose. Consider Fentanyl 1-2 mcg/kg IV/IO/IN (max 150 mcg). Click "calculate" to get dose.

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• SEDATE:
• Ketamine 1-2 mg/kg IV/IO (60 second onset and 10 minute duration).
• Click "calculate" to get dose.
• OR Etomidate 0.3 mg/kg IV/IO (30 second onset and 3 minute duration).
• Click "calculate" to get dose.

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• PARALIZE: Consider delayed paralysis to allow pre-oxygenation.
• Delayed: Rocuronium 0.1 mg/kg [ideal body weight] IV/IO (2 minute onset and 10 minute duration).
• Click "calculate" to get dose.
• Enter height and click "calculate" to get dose based on IDEAL weight.
• Rapid: Rocuronium 1.2 mg/kg [ideal body weight] IV/IO (1 minute onset and 30 minute duration).
• Click "calculate" to get dose.
• Enter height and click "calculate" to get dose based on IDEAL weight.

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• CONTINUED SEDATION:
• Consider Ketamine 1 mg/kg IV/IO.
• Click "calculate" to get dose.

• Adult:	Pediatric:
  Consider Versed 2.5-5 mg IV/IO every 5 minutes as needed maintaining SBP greater than 100. Consider Fentanyl 5-100 mcg IV/IO/IN (max 300 mcg).	Over 12 years old: Consider Versed same dose as adult. 2 months to 12 years old: Consider Versed 0.15 mg/kg IV/IO. May repeat every 5 minutes. Click "calculate" to get dose. Consider Fentanyl 1-2 mcg/kg IV/IO/IN (max 150 mcg). Click "calculate" to get dose.

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• CONTINUED PARALYSIS:
• Signs of patient movement AFTER fully sedated: Rocuronium 0.1 mg/kg ideal body wight IV/IO.
• Click "calculate" to get dose.
• Enter height and click "calculate" to get dose based on IDEAL weight.

Medic:

• Ensure completion of applicable items above.

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• INTUBATE:
• Elevate head of Cot.
• Consider Suction.
• Consider Bougie.
• Click "calculate" to get equipment sizes.
• Maximum of three attempts, then Supraglottic Airway should be used.
• Confirm with Waveform Capnography.
• Consider Ventilator.
• Consider gastric tube.
• May proceed to cricothyrotomy if patient’s anatomy precludes oral tracheal intubation. Such as severe facial trauma that prevents other ventilation methods from being effective.

CP:

• Ensure completion of applicable items above.

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