Drug Assisted Intubation

Patients who require intubation have at least one of the following 5 indications:

• 1. Failure to ventilate
• 2. Inability to maintain airway patency
• 3. Inability to protect the airway against aspiration
• 4. Failure to adequately oxygenate
• 5. Anticipation of an injuries or illness that will eventually lead to the inability to maintain airway patency i.e. Angio Edema, Bad Strep Infection, Ludwig’s Angioedema etc.

The (7) Seven P’s of DAI

• 1. Prepare
• 2. Pre-oxygenate
• 3. Pretreatment / Treatment
• 4. Paralysis if needed
• 5. Protection and positioning
• 6. Placement and proof
• 7. Post-intubation management

Prepare:

• Have all emergency airway supplies prepared and ready, (i.e. Bougie Tube, King Vision, King Airway, Cric-kit) Pre-oxygenate:
• If time permits, pre-oxygenate all patients via NRBM or BVM. 2 Person BVM is recommended once medications are administered. Pretreatment / Treatment:
• Consider Lidocaine 1.5mg/kg for patients with increased Intracranial pressure. (i.e. head trauma, brain tumor, stroke.) *Administer as early as possible prior to intubation.
• Administer Fentanyl: Adult 3mcg/kg. Pediatric 1-2mcg/kg.
• Administer Etomidate: Adult 20mg, Max 40mg Lg Adult. Pediatric 0.3mg/kg Max 20mg.
• Administer Ativan: Adult 0.5- 2mg
• Administer Morphine: Adult 2-20mg

Intubation attempt should be made after Fentanyl or Etomidate is administered.

Paralytics if needed:

• If intubation is unsuccessful due to the patient being clinched, strong gag reflex, or seizure, consider Succinylcholine: Adult 1.5mg/kg. Pediatric 2mg/kg.
• Do not administer to patients with Hx of HYPERKALEMIA, RHABDOMYOLYSIS, Severe Burns and Malignant hyperthermia. (i.e. peaked T waves, kidney insufficiency, renal failure, acidosis, crush injuries.)
• If ventricular dysrhythmias are present after medication administration, consider Calcium Chloride.

Placement and proof:

• Allow medications to work.
• Maintain Sellick’s maneuver until cuff inflated.
• Ventilate with bag-valve mask if unsuccessful.
• Confirm tube placement EtCO2 and lung sounds.
• Visualize the ET tube passing through the vocal cords.
• st-intubation management:
• Secure endotracheal tube with commercially available device
• Continued sedation (i.e. Versed) (watch for hypotension) consider Fentanyl for pain and sedation
• Continuous SaO2 and EtCO2 monitoring
• Reassess vital signs frequently
• Restrain patient to prevent accidental extubation

ONCE THE DECISION IS MADE TO PERFORM (DAI), THE LEAD PARAMEDIC MUST CONSIDER THE FOLLOWING:

• 2 PERSON BVM.
• ESTABLISH THE AIRWAY - IF INTUBATION ATTEMPTS FAIL, RETURN TO BVM USE AND TRY TO KEEP SaO2 ABOVE 92% DURING ADDITONAL ATTEMPTS.
• IF UNABLE TO ESTABLISH A SUCCESSFUL INTUBATION OR VISUALIZE THE VOCAL CORDS, THE USE OF BOUGIE TUBE AND KING VISION CAMERA SHALL BE PERFORMED.
• AN ATTEMPT TO PLACE THE KING AIRWAY SHALL BE MADE.
• IF THE KING AIRWAY FAILS, RETURN TO BVM.
• IF UNABLE TO VENTLATE VIA BLS BVM PERFORM SURGICAL CRICOTHYROTOMY