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Endotracheal Intubation (CPG A0302)

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Care Objectives

  • Ensure safe and effective airway management throughout entire episode of care.

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General Notes

  • Minimising scene times should be prioritised over the decision to perform prehospital RSI.

  • In rural areas, RSI may be undertaken or withheld by Advanced Paramedics following consideration of risk-benefit analysis.

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Rapid Sequence Intubation (RSI)

  • Ketamine is the preferred sedation induction agent for all RSI unless contraindicated by BP > 180
    mmHg in the setting of NTBI.

  • Fentanyl and Midazolam dosage should be based on assessment of cardiovascular and frailty status
    at the time of RSI.

  • Patients with traumatic brain injury should receive hemodynamic support via Normal Saline 10
    mL/kg     during preparation for RSI, however administration must not delay RSI.

  • Calculated Ketamine and Rocuronium doses should be rounded up to the nearest 10 mg.

  • Avoid Fentanyl and Ketamine administration in the setting of serotonin syndrome/hyperthermia by
    using Morphine and Midazolam to facilitate RSI.

  • Pre-RSI combativeness in TBI should be managed judiciously with analgesia as per CPG A0501 Pain
    Relief.

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Advanced Paramedic

  • Standard Induction & Paralysis

    • Ketamine 1.5 mg/kg IV or 4 mg/kg IM (max. 200 mg)

    • If GCS ≥ 10: Midazolam 5 mg IV

    • Rocuronium 1 mg/kg IV (max. 100 mg)

  • Modified Induction & Paralysis (ketamine contraindicated)

    • Fentanyl 100 - 200 mcg IV

    • Midazolam 5 - 10 mg IV

    • Rocuronium 1 mg/kg IV (max. 100 mg)

  • Delayed Sequence Intubation (combative/hypoxic respiratory failure preventing pre-oxygenation)

    • Ketamine 1.5 mg/kg IV or 4 mg/kg IM (max. 200 mg)

    • Preoxygenate for 3 minutes

    • Rocuronium 1 mg/kg IV (max. 100 mg)

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Action - Placement

  • Sight the ETT through the vocal cords and position appropriately via American Standard markings

  • Note length at lips

  • Post-intubation capnography is essential for confirmation of tracheal placement and must be noted by all paramedics. If there is any doubt about tracheal placement the ETT must be immediately removed.

  • Supplementary checks:

    • ​Capnometry

    • Rise and fall of chest

    • Auscultation

    • SpO2

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Flow Chart - Indications & Preparation

ETI Indications Flowchart.jpg
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Flow Chart - Procedure

ETI Procedure Flowchart.jpg
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