Pharmacologically-Assisted Intubation (optional procedure)

Inclusion Criteria: It may be necessary on occasion to sedate and/or utilize neuromuscular blockade before or during transport to facilitate intubation of the patient with a compromised airway when standard methods have failed or would delay care. Only adequately trained Paramedics following 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 CVA needing mild hyperventilation
  
• Burn patient with airway involvement and inevitable airway loss
  
• Severe asthma or COPD with hypoxia and respiratory exhaustion
  
• Overdoses, (i.e. tricyclics) where loss of airway in inevitable
  
• Any combative, agitated, or confused patient who needs definitive airway control
  
• Any other patient approved by a Medical Control 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 is present, there are no contraindications.


PROCEDURE:

          THREE (3) MINUTES PRIOR TO INTUBATION:

1. Preoxygenate and Prepare
   a.      Allow the patient to breathe 100% oxygen by mask (assist ventilation only if absolutely necessary).
   b.     Connect patient to ECG monitor (monitor for dysrhythmias), pulse oximeter, and waveform capnography.
   c.      Ensure functioning and secure IV access (functioning tibial IO is acceptable)
   d.      Assemble required equipment and personnel
            i.      Pharmacologically-Assisted Intubation Checklist
            ii.     Oral airway, suction, O2, ET tube, stylet, laryngoscope, BVM, device to secure tube, appropriately sized cervical collar
            iii.     PAI and pretreatment medications (two rescuers MUST confirm the appropriate drug dosages)
            iv.    At least three rescuers are necessary (1 for intubation,1 for medication administration and Sellick maneuver, and 1 time keeper/monitor.
   
   
   TWO (2) MINUTES PRIOR TO INTUBATION:
   
   
2. Premedicate ( as appropriate ) - administer
   a.      Lidocaine 1 mg/kg, if head injury or stroke is suspected and no contraindications exist
   b.      Atropine 0.01 mg/kg, if patient is less than 13 years of age and no contraindications exist
   
   
   ONE (1) MINUTE PRIOR TO INTUBATION:
   
   
3. Sedate
   a.      Etomidate, 0.3 mg/kg slow IV push over 30 seconds if no contraindications exist
   b.      At the first sign of sedation, perform Sellick maneuver.
   c.      If sufficient sedation does not occur within three minutes, administer additional etomidate dose of 0.1 mg /kg as needed to achieve sedation to a maximum total dose of 40 mg.
   
   Alternatively
   
   3.  Sedate
            a.      Midazolam, 0.1 mg/kg slow IV push to a maximum single dose of 5 mg
            b.     Fentanyl, 1.0 mcg/kg slow IV push to a maximum single dose of 200 mcg
            c.      At the first sign of sedation, perform Sellick maneuver.
   
   NOTE: Agencies are not required to carry medications for both sedation procedures.
   
   
   INTUBATIUON TIME
   
   
4. Perform orotracheal intubation within 30 seconds.
   a.      If unsuccessful, ventilate with BVM and 100% oxygen with slow steady ventilation.
   b.      Abandon intubation attempt and ventilate with 100% oxygen if ANY of the following events occur:
            i.       Heart rate falls by 10 beats per minute below baseline
            ii.      Pulse oximeter falls by 10 percentage points below baseline
            iii.     Capnometer rises by 5 mmHg above baseline
   c.      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 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. Patient shall remain on monitor, pulse oximeter and capnography until care is transferred to the emergency department staff.
   
10. If patient exhibits movement that might lead to extubation administer
    a.      Diazepam 5 mg - 10 mg IV push, or
    b.     Midazolam 2.5mg - 5mg IV push, or 10 mg intranasally
    
    

<--back to table of contents