‘Standard’ RSI Protocol – normotensive, neurological stable.
1. Check neck for potential cric, have cric kit and LMA available
2. Positioning – sniffing position, ideally head up.
3. Check for dentures – in for bag mask, out for intubation.
4. Preoxygenation – 100% NRB 15 lpm x 3 minutes or flow via BVM
5. Attach in line EtCO2 monitor to BVM
6. Have OPA and NPA available in proper size.
7. Have LMA available with syringe and lubricant.
8. Pick ET tube. Check balloon with 10 cc air, leave syringe attached. Place stylet or have bougie handy.
9. +/-‘Lube the tube’ – put small amount of sterile lube jelly on ETT tip
10. Choice of laryngoscope. Check bulb working.
11. Suction – turn on, place handle under right shoulder of patient or under pillow.
12. Have Epinephrine push dose on hand – 5-10 mcg/kg IV or Phenylnephrine 100 mcg/ml
13. Pretreatment agent? – Fentanyl 3 mcg/kg
14. Induction agents – Ketamine 2 mg/kg or Propofol 1.5 – 3 mg/kg (or Midazolam 0.3 mg/kg TBW)
15. Neuromuscular blocking agents – Succinylcholine 2 mg/kg or Rocuronium 1.2 mg/kg
16. Cricoid pressure – BURP
17. Intubate – place ETT 23 cm to lips for males, 21 cm to lips for females. Inflate balloon. Secure tube.
18. Confirm – listen to chest, check EtCO2
19. Order CXR to confirm ETT depth
20. Post intubation medications – Fentanyl or morphine infusion. +/- sedation
21. Place NG tube, in line suction
22. Head of bed up 30-45 degrees.
23. Foley catheter.
24. Ventilator settings.
Mode: AC
FiO2 100%
RR 10-14 bpm
Tidal Volume 8 cc/kg IBW
PEEP? 5 or as needed.
25. ABG within 30 minutes post intubation.
Hypotensive/Shock
1. Check neck for potential cric, have cric kit and LMA available
2. Positioning – sniffing position, ideally head up
3. Check for dentures, in for Bag Mask, out for intubation.
4. Preoxygenation – 100% NRB 15 lpm x 3 minutes or flow through BVM
5. Attach in line EtCO2 monitor to BVM
6. Have OPA and NPA available in proper size.
7. Have LMA available with syringe and lubricant.
8. Pick ET tube, test balloon with 10 cc air, leave syringe on. Place stylet or have bougie handy
9. +/- Lube the tube – place small amount sterile lub on ETT tip.
10. Choice of laryngoscope. Check bulb working.
11. Suction – turn on, place handle under Rt shoulder of patient or under pillow
12. Have epinephrine push dose – 5-10 mcg IV push prn or norepinephrine infusion ready
13. Consider scopolamine 0.4 mg IV
14. Induction agents – Ketamine 0.25 mg/kg or Propofol 0.1 – 0.15 mg/kg
15. Neuromuscular blocking agents – Succinylcholine 2 – 2.5 mg/kg
16. Cricoid pressure – BURP
17. Intubate – place ETT 23 cm to lips for males, 21 cm to lips for females. Inflate balloon.
18. Confirm – listen to chest, check EtCo2
19. Order CXR to confirm ETT depth
20. Post intubation medications – Fentanyl or morphine infusion. +/- sedation
21. Place NG tube, in line suction.
22. Head of bed up 30-45 degrees
23. Ventilator settings.
Mode: AC
FiO2 100%
RR 14
Tidal Volume 6-8 cc/kg IBW
PEEP ? 5 or as needed.
24. Foley catheter
25. ABG within 30 minutes of intubation.
Elevated ICP
1. Check neck for potential cric, have cric kit and LMA available
2. Positioning – sniffing position, ideally head up.
3. Check for dentures – in for bag mask, out for intubation.
4. Preoxygenation – 100% NRB 15 lpm x 3 minutes or flow via BVM
5. Attach in line EtCO2 monitor to BVM
6. Have OPA and NPA available in proper size.
7. Have LMA available with syringe and lubricant.
8. Pick ET tube. Check balloon with 10 cc air, leave syringe attached. Place stylet or have bougie handy.
9. +/- Lube the tube – small amount of sterile lub on end of ETT
10. Choice of laryngoscope. Check bulb working
11. Suction – turn on, place handle under Rt shoulder of patient or under pillow
12. Have Labetalol 20-25 mg IV on hand for elevated systolic pressure.
13. Have push dose epinephrine on hand – 5 – 10 mcg IV
14. Induction agents – Ketamine 2 mg/kg
15. Neuromuscular blocking agents – Succinylcholine 2 mg/kg
16. Cricoid pressure – BURP
17. Intubate – place ETT 23 cm to lips in males, 21 cm to lips in females. Inflate balloon.
18. Confirm – listen to chest, check EtCO2
19. Order CXR to confirm ETT depth
20. Post intubation medications – Fentanyl or morphine infusion, +/- sedation
21. Place NG tube, in line suction.
22. Head of bed up 30-45 degrees
23. Ventilator settings.
Mode: AC
FiO2 100%
RR 14 -18 bpm
Tidal Volume 8 cc/kg IBW
PEEP ? 5 or as needed.
24. Foley catheter
25. ABG within 30 minutes of intubation.
Asthmatic
1. Check neck for potential cric, have cric kit and LMA available
2. Positioning – sniffing position, ideally head up
3. Check for dentures – in for bag mask, out for intubation.
4. Preoxygenation – 100% NRB 15 lpm x 3 minutes
5. Attach in line EtCO2 to BVM
6. Have push dose epinephrine on hand – 5 – 10 mcg IV
7. Pick ET Tube, test balloon with 10 cc air, leave syringe on. Place stylet or have bougie handy
8. +/- ‘Lube the tube’ – small amount of sterile lube to ETT tip.
9. Suction – turn on, place handle under Rt shoulder of patient or under pillow. \
10. Have push dose epinephrine on hand – 5 – 10 mcg IV
11. If time permits can give Lidocaine 1.5 mg/kg 3 minutes prior
12. Induction agents – Ketamine 2 mg/kg
13. Neuromuscular blocking agents – Rocuronium 1.2 mg/kg or Succinylcholine 2 mg/kg
14. Cricoid pressure – BURP
15. Intubate – place ETT 23 cm to lips in males, 21 cm to lips in females. Inflate balloon.
16. Confirm – listen to chest, check EtCO2
17. Order CXR to confirm depth.
18. Post intubation medications – Fentanyl infusion. (not morphine)
19. Ventilator settings.
Mode: AC
FiO2 100%
RR 6-10 bpm
Tidal Volume 8 cc/kg IBW
PEEP zero initially
Set inspiratory time to less than 1 second (0.8)
20. Give bronchodilators via vent.
21. Foley catheter.
22. ABG within 20 minutes of intubation
All of the above intubation protocols must also be viewed in a wider context of the resuscitation. Although
much of what you as team leader are doing is getting and checking equipment, there are other actions that need
to be done concurrently including:
1.
2.
3.
4.
5.
6.
7.
If the patient is being actively ventilated by BVM, ensure they are ventilating at a rate of ~ 10-12 per
minute, with appropriate compression of the bag to deliver 6-8 cc.kg IBW. Have they an OPA or NPA?
Ensure patient is hooked up to monitor (or better yet to Lifepac) with Oxygen saturations, heart rhythm,
EtCO2.
Ask someone to get the ventilator, hook it up to wall oxygen, plug it in and if possible have them enter
the settings you want. Use ‘ask to be told’ communication so the RN tells you when they are ready.
Ensure the other aspects of the resuscitation are occurring, such as IV fluids being administered in
appropriate amounts, blood products being ordered if appropriate, maintaining patient ‘normothermia’
(ie cover patient with blankets),
Ask x-ray to be on hand for post intubation CXR
Designate RN to draw up the medications. Use ‘ask to be told’ communication so that the RN tells you
when they are ready.
Before the actual intubation if time permits do a ‘group check’. Ask if anyone thinks something has been
omitted, needs changes etc.