Immediately place LMA/SGA, call for advanced airway provider
Contraindications to NG/OG tube placement?
#2 intubation attempt
Place surgical airway, off pathway
Confirmation of placement checklist (minimum)
Concern for COPD or asthma?
IV access established x2?
C-Collar present?
< 2 months old?
Patient requires positive pressure ventilation?
2 attempts by trained provider at peripheral IV access (max time 60 seconds)
Select sedation/induction agent
Status epilepticus or < 1 years old?
Concern for COPD or asthma?
Catecholamine depleted shock?
Select paralytic medication
< 1 years old?
NG/OG tube placement
Obstructive strategy
< 10 years?
Optimize oxygenation (PEEP + FiO2)
Goal PaO2 55-80 mmHg or SpO2 88-95% Use a minimum PEEP of 5 cm H2O
FiO2 | PEEP |
0.3 | 5 |
0.4 | 5 |
0.4 | 8 |
0.5 | 8 |
0.5 | 10 |
0.6 | 10 |
0.7 | 10 |
0.7 | 12 |
0.7 | 14 |
0.8 | 14 |
0.9 | 14 |
0.9 | 16 |
0.9 | 18 |
1.0 | 18-24 |
Post-intubation care
Contraindications to Succinylcholine?
Successful bag-mask ventilation?
Bag-mask ventilation with PEEP valve
Intraossous line placement
Consider intubation without paralytics. May consider adding analgesia such as morphine. Also may consider placing OG tube prior to intubation to evacuate stomach.
In-line stabilization
Optimize panoxygenation (preoxygenation + apnic oxygenation)
Complete timeout and checklist
< 1 yrs or < 5 yrs with SCh?
2 mg/kg (< 2 years), 1.5 mg/kg (> 2 years) - max 200 mg
#1 intubation attempt
Consider video larnygoscopy (especially VL/DL combination devices)
Checklist verbalized, give sedation and paralytic medications
Signs of potential difficult airway
Indications for RSI
Fentanyl 2 mcg/kg bolus then 1 mcg/kg/hr
Any one of the following
Head positioning to optimize airway (sniffing position with ear canals level with sternal notch)
If patient has g-tube, consider venting prior to intubation attempts.
Modifiable intubation techniques for each attempt
Attempt defined as any time the laryngoscope enters the mouth
Drug (IV) | Onset | Duration |
Ketamine | 30 sec | 5-10 min |
Etomidate | 30-60 sec (peak 1 min) | 3-5 min |
Succinylcholine | < 60 sec | 4-6 min |
Rocuronium | 1-2 min (peak 4 min) | 30 min |
Vecuronium | 2-3min (peak 3-5 min) | 25-40 min |
Fentanyl | 30 sec | 30 min - 1 hour |
Midazolam | 3-5 min | < 2 hours |
If at any point ventilation becomes severely compromised, immediately progress to surgical airway
Propofol 0.5 mg/kg bolus then 20 mcg/kg/min, titrate to adequate sedation
Consult advanced airway provider
Obtain primary equipment
Obtain backup equipment
Contraindications to Succinylcholine
Off pathway, consider repositioning and surgical airway
Comparing Paralytics
Rocuronium | Succinylcholine | |
Depolarizing | No | Yes |
Onset | 30 sec | 5-10 sec |
Time to intubation | 90 sec (at 1-1.2 mg/kg) | 30-60 sec (at 1.5-2 mg/kg) |
Fasciculations | No | Yes |
Duration | 45-60 min | 8-15 min |
Pretreatment medications
Atropine
Lidocaine
Opiates
Defasciculating dose of paralytics
#3 intubation attempt
Suggested age specific ventilation rates (titrate as needed)
0 - 2 mo | 30 bpm |
2 mo - 1 yr | 25 bpm |
1 yr - 2 yrs | 22 bpm |
2 yrs - 10 yrs | 20 bpm |
> 10 yrs | 18 bpm |
Protective strategy
Richmond agitation-sedation scale (RASS) scoring system
Points | Criteria |
1 |
|
2 |
|
3 |
|
4 |
|
Label | Description | |
+4 | Combative | Combative, violent, immediate danger to staff |
+3 | Very Agitated | Pulls to remove tubes or catheters; aggressive |
+2 | Agitated | Frequent non-purposeful movements, fights ventilator |
+1 | Restless | Anxious, apprehensive, movements not aggressive |
0 | Alert & calm | Spontaneously pays attention to caregiver |
-1 | Drowsy | Not fully alert, but has sustaind awakening to voice (more than 10 sec) |
-2 | Light sedation | Briefly awakens to voice (less than 10 sec) |
-3 | Moderate sedation | Movement or eye opening to voice |
-4 | Deep sedation | No response to voice, but movement or eye opening to physical stimulation |
-5 | Unarousable | No response to voice or physical stimulation |
Calculate sedation score (RASS, N-PASS, COMFORT, etc.) and select post-intubation sedation
NOTE: All intubations should be approached as 'difficult' no matter what the underlying assumptions may be.
Intubation by advanced airway provider?