PHARMACOLOGICALLY-ASSISTED INTUBATION (PAI) – (OPTIONAL PROCEDURE)

Inclusion Criteria:  It may be necessary on occasion to sedate and/or utilize neuromuscular blockade before or during transport in order to facilitate intubation of the patient with a compromised airway when standard methods have failed or would delay care.  Only adequately trained Paramedics with Medical Director clearance may perform this procedure.  At least three rescuers are necessary to perform this procedure safely.

INDICATIONS:

• Trauma patient with GCS less than or equal to eight (8) with an intact gag reflex
• Trauma patient with significant facial trauma and poor airway control
• Closed head injury or hemorrhagic stroke needing mild hyperventilation
• Burn patient with airway involvement and anticipated airway loss
• Severe asthma or COPD with hypoxia and respiratory exhaustion
• Overdoses, (i.e. tricyclic anti-depressants) where loss of airway is anticipated
• Any combative, agitated, or confused patient who needs definitive airway control
• Any other patient approved by a Medical Command Physician at BioTel

Special Note:

A quick, but detailed, notation of pre-intubation neurological status is required for head injury and stroke patients.

CONTRAINDICATIONS:

When any of the indications are present, there are no contraindications.

PROCEDURE:

THREE (3) MINUTES PRIOR TO INTUBATION:

1. Pre-oxygenate and Prepare:
1. Allow the patient to breathe 100% oxygen by mask (assist ventilation only if absolutely necessary).
2. Institute continuous monitoring of ECG (monitor for dysrhythmias), pulse oximetry, and waveform capnography.
3. Ensure functioning and secure IV access (functioning IO is acceptable).
4. Assemble required equipment and personnel:
1. Pharmacologically-Assisted Intubation Checklist
2. Oral airway, suction, O₂, ET tube, stylet, laryngoscope, BVM, device to secure tube, and an appropriately sized cervical collar
3. PAI and pretreatment medications (two rescuers MUST confirm the appropriate drug dosages)
4. At least three rescuers are necessary (1 for intubation, 1 for medication administration and possible Sellick maneuver (if needed), and 1 time keeper/monitor)

TWO (2) MINUTES PRIOR TO INTUBATION:

2. Premedicate (as appropriate) – administer:
1. Lidocaine 1 mg/kg, if head injury or stroke is suspected and no contraindications exist; AND
2. Atropine 0.01 mg/kg (0.1 mL/kg), if the patient is less than 13 years of age and no contraindications exist

ONE (1) MINUTE PRIOR TO INTUBATION:

3. Sedate:
1. Etomidate, 0.3 mg/kg slow IV/IO push over 30 seconds, if no contraindications exist
1. If sufficient sedation does not occur within three minutes, administer one additional etomidate dose of 0.1 mg /kg as needed to achieve sedation, up to a maximum, cumulative, total dose of 40 mg.
2. Pediatric dose: 0.6 mg/kg IV/IO cautiously over 30 seconds.

Alternatively

3. Sedate:
   1. Ketamine, 2 mg/kg IV/IO, if etomidate is unavailable and if no contraindications exist
      1. Pediatric dose: 2 mg/kg IVP/IO cautiously over 1 minute, or 3 to 5 mg/kg IM

Alternatively

3. Sedate:
1. Midazolam, 2.5 to 5 mg slow IV/IO, up to a maximum single dose of 5 mg;
1. Pediatric dose: 0.1 mg/kg slow IV/IO, up to a maximum of 5 mg.
2. AND
3. Fentanyl, 1.0 mcg/kg slow IV/IO, up to a maximum single dose of 200 mcg;
1. Pediatric dose: 1.0 mcg/kg IV/IO, up to a maximum of 100 mcg 

NOTE:  Agencies are not required to carry medications for all sedation procedures.

INTUBATION TIME:

4. Perform orotracheal intubation within 30 seconds:
1. If unsuccessful, ventilate with BVM and 100% oxygen with slow steady ventilation.
2. Abandon intubation attempt and ventilate with 100% oxygen if ANY of the following events occur:
1. Heart rate falls by 10 beats per minute below baseline
2. SpO2 falls by 10 percentage points below baseline
3. ETCO2 rises by 5 mmHg above baseline
3. If unable to intubate the trachea in one attempt, insert an approved supraglottic airway device.

THIRTY (30) TO SIXTY (60) SECONDS FOLLOWING INTUBATION:

5. Confirm tube placement with physical exam techniques and waveform capnography.
6. Secure tube and restrict movement of the patient’s head with a cervical collar and tape.
7. Acquire rhythm strip of ECG rhythm, current vital signs, and capnography waveform.
8. Complete post-sequence checklist.

DURING TRANSPORT:

9. Implement continuous ECG, SpO2 and ETCO2 monitoring until care is transferred to the ED staff.
10. If the patient exhibits movement, coughing or other activity that might lead to extubation, administer:
1. Diazepam 2.5 mg to 5 mg IV/IO/IM/IN (May repeat once after 15 minutes);
1. Pediatric dose: 0.1 mg/kg IV/IO/IM/IN (May repeat once, after 15 minutes);
2.  OR
3. Midazolam 2.5mg to 5 mg IV/IO/IM/IN (May repeat once after 15 minutes);
1. Pediatric dose: 0.1 mg/kg IV/IO/IM/IN (May repeat once, after 15 minutes);
4. For additional dosing authorization, contact BioTel.