Advanced Airway Management and RSI: Concepts for Paramedics

By Jointra Editorial Team, Certified EMT

The Pre-Hospital Airway Hierarchy

Managing the airway is the first priority in resuscitation, but not every patient requires endotracheal intubation. The pre-hospital airway hierarchy moves from least invasive to most invasive:

1. Positioning and jaw thrust 2. Supplemental oxygen (NRB, nasal cannula) 3. BVM ventilation 4. Supraglottic airway (King LT, i-gel, LMA) 5. Endotracheal intubation (ETI) 6. Surgical airway (cricothyrotomy)

The goal is to use the least invasive intervention that adequately manages the airway.

Indications for Intubation

• Failure to protect the airway (GCS ≤8 with absent gag reflex, loss of protective airway reflexes)
• Respiratory failure despite supplemental oxygen (PaO2 <60 mmHg, PaCO2 >50 mmHg, or clinical failure)
• Anticipated deterioration (anaphylaxis with airway edema, inhalation injury, angioedema)
• Need for positive pressure ventilation (severe pulmonary edema, severe asthma refractory to treatment)

Rapid Sequence Intubation

RSI involves the simultaneous administration of a sedative and a neuromuscular blocking agent to achieve rapid unconsciousness and paralysis for intubation. The sequence:

1. Preparation

• Equipment check: laryngoscope, ET tube (7.0–8.0mm for adults), suction, BVM, backup supraglottic airway, surgical airway kit
• IV/IO access confirmed
• Monitoring: SpO2, EtCO2, cardiac monitor, BP

2. Preoxygenation

• 3 minutes of 100% O2 via NRB or BVM (passive oxygenation)
• Goal: SpO2 >95% (or 100% if possible) before induction
• Apneic oxygenation: high-flow nasal cannula at 15 LPM during attempt maintains oxygenation

3. Pretreatment (situational)

• Lidocaine 1.5mg/kg IV — may blunt ICP spike in head trauma (limited evidence)
• Atropine 0.01mg/kg — pediatric patients receiving succinylcholine to prevent bradycardia

4. Induction (sedative)

• Ketamine 1.5–2mg/kg IV — preferred in hemodynamically unstable patients; dissociative anesthetic with bronchodilatory properties. Increases heart rate and BP.
• Etomidate 0.3mg/kg IV — hemodynamically neutral; single-dose adrenal suppression is clinically debated
• Midazolam 0.1mg/kg IV — benzodiazepine; significant hemodynamic depression; avoid in hypotensive patients

5. Paralytic

• Succinylcholine 1.5mg/kg IV — depolarizing; onset 45–60 seconds; duration 8–12 minutes. Contraindicated in hyperkalemia, crush injury >72h, burns >72h, neuromuscular disease
• Rocuronium 1.2mg/kg IV — non-depolarizing; onset 60–90 seconds at high dose; duration 45–60 minutes. Reversed by sugammadex 16mg/kg

6. Intubation

• Direct laryngoscopy or video laryngoscopy
• Visualize cords, pass tube, inflate cuff
• Confirm placement: EtCO2 (gold standard), bilateral breath sounds, chest rise, absence of epigastric sounds

7. Post-intubation management

• Continuous waveform capnography (target EtCO2 35–45 mmHg; 30–35 in suspected elevated ICP)
• Long-acting sedation (midazolam, fentanyl)
• Neuromuscular blockade if needed for transport
• Ventilator settings: tidal volume 6–8 mL/kg IBW, rate 10–12/min

Complications and Rescue

Esophageal intubation — absence of EtCO2 waveform is the most reliable indicator. Remove tube immediately, ventilate with BVM, reattempt.

Right mainstem intubation — decreased breath sounds on left. Withdraw tube 1–2 cm.

Can't intubate, can't oxygenate (CICO) — failed ETI + failing SpO2 despite BVM + failed supraglottic. Surgical airway (needle or surgical cricothyrotomy) without delay.