Rapid sequence intubation and post-intubation sedationMANAGEMENT

RESPIRATORY PRESENTATIONS · 12 SECTIONS

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565 items

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01Approach to the Critical Patient/attcp60

Resuscitate before you intubate

›Resuscitation sequence precedes induction whenever the patient is not in extremis

›Correct hypotension before pushing induction agents

›SBP <90 mmHg or MAP <65 mmHg pre-intubation predicts peri-intubation cardiac arrest

›Push-dose vasopressor or fluid bolus given before laryngoscopy, not after arrest

›Pre-oxygenation and apneic oxygenation started before drugs are drawn up

›Non-rebreather mask at 15 L/min or bag-valve-mask with PEEP valve for 3 minutes, or 8 vital capacity breaths if cooperative

›Nasal cannula at 15 L/min left in place under the mask and continued through the apneic period

›Target SpO2 >=95% before laryngoscopy when achievable

›Correct severe acidosis physiology before paralysis

›Paralysis abolishes the compensatory hyperventilation driving pH in DKA and salicylate toxicity

›If intubation cannot be delayed, set initial ventilator rate to match or exceed the patient's pre-intubation minute ventilation

›Push-dose vasopressors for peri-intubation hypotension

›Phenylephrine 100 mcg IV push (range 50 to 200 mcg) from a 100 mcg/mL dilution, repeat every 2 to 5 minutes

›Avoid as sole agent in cardiogenic shock or bradycardia; pure alpha-agonism causes reflex bradycardia and no inotropy

›Epinephrine 10 mcg IV push (range 5 to 20 mcg) from a 10 mcg/mL dilution, repeat every 2 to 5 minutes

›Preferred push-dose agent when inotropy is also needed (cardiogenic physiology, undifferentiated shock)

›Mix by adding 1 mL of cardiac-arrest epinephrine (0.1 mg/mL) to a 100 mL saline bag to yield 1 mcg/mL

›Continuous vasopressor infusion started in parallel if repeat pushes are required

›Push-dose agents are a bridge, not a substitute for infusion therapy

Physiologically difficult airway and peri-intubation arrest

›The physiologically difficult airway (HOp Killers) independent of anatomy

›Hypoxemia

›SpO2 <90% despite maximal pre-oxygenation and apneic oxygenation

›Apneic time to critical desaturation is shortened; plan for immediate rescue with a supraglottic device

›Hypotension

›SBP <90 mmHg or MAP <65 mmHg pre-intubation

›Correct before induction; have push-dose pressor drawn up at the bedside regardless

›Severe metabolic acidosis

›pH <7.2

›Loss of respiratory compensation with apnea can precipitate arrest within minutes

›Right ventricular failure

›Positive pressure ventilation increases RV afterload and drops preload simultaneously

›Recognized in massive pulmonary embolism, RV infarct, and decompensated pulmonary hypertension

›Predictors of peri-intubation cardiac arrest

›Pre-intubation SBP <90 mmHg

›Pre-intubation SpO2 <90%

›Shock index (HR/SBP) >0.9 before induction

›Age >75 years

›No fluid bolus given despite an indication for one before induction

›Mechanism of peri-intubation hemodynamic collapse (the "three hits")

›Loss of endogenous catecholamine drive from the induction agent

›Most pronounced with propofol; least pronounced with etomidate and ketamine

›Initiation of positive pressure ventilation reduces venous return

›Unmasks occult hypovolemia

›Loss of the negative intrathoracic pressure that was augmenting preload

›Compounded by any PEEP applied at the first ventilator breath

Team roles, equipment, and rescue readiness

›Role assignment before drugs are given

›Airway operator, medication nurse, monitor/vitals caller, and a dedicated documenter

›Closed-loop communication for every drug given and every vital sign change

›Backup airway operator identified in advance for an anticipated difficult airway

›Difficult airway and failed airway equipment at the bedside

›Video laryngoscope as the primary device in most contemporary EDs

›Improves glottic view without reliably changing first-pass success at all operator skill levels

›Bougie available on every attempt

›Supraglottic airway device sized and ready for immediate rescue

›Surgical airway kit opened and marked for a failed airway/failed oxygenation scenario

›Failed airway algorithm activation criteria

›Failed intubation attempts with inability to oxygenate by bag-mask or supraglottic device

›Proceed directly to a surgical airway without further intubation attempts

›Cannot intubate, cannot oxygenate (CICO) scenario

›Cricothyrotomy without delay

02History/hx33

Airway and anesthesia history

›Prior airway and anesthesia experience

›Previous difficult intubation or difficult bag-mask ventilation

›Anesthesia record or medical-alert documentation

›Prior tracheostomy or airway surgery

›Subglottic stenosis risk

›Obstructive sleep apnea diagnosis

›Predicts difficult bag-mask ventilation and rapid desaturation

›Malignant hyperthermia and neuromuscular history

›Personal or family history of malignant hyperthermia

›Absolute contraindication to succinylcholine and volatile anesthetics

›Known neuromuscular disease (myasthenia gravis, ALS, muscular dystrophy)

›Altered sensitivity to both depolarizing and nondepolarizing agents

›Denervation injury history: stroke, spinal cord injury, prolonged immobilization, Guillain-Barre syndrome

›Succinylcholine contraindicated beginning approximately 3 to 5 days after the injury and persisting for up to 6 months to 2 years

›Allergy and prior anesthetic reaction history

›Egg, soy, or prior propofol reaction

›Prior anaphylaxis to a neuromuscular blocking agent

›Current medications affecting drug selection

›Beta-blockers and calcium channel blockers blunting the sympathetic response to laryngoscopy

›Chronic opioid or benzodiazepine use raising sedation and analgesia requirements

›Anticoagulant or antiplatelet therapy raising bleeding risk with traumatic attempts

Physiologic risk factors for peri-intubation deterioration

›History suggesting occult shock

›Poor oral intake, vomiting, diarrhea, or polyuria preceding presentation

›Ongoing hemorrhage source (GI bleed, trauma, ectopic pregnancy)

›History suggesting right ventricular strain

›Recent immobilization, malignancy, or prior VTE suggesting pulmonary embolism

03Physical Exam/exam30

Anatomically difficult airway predictors

›LEMON assessment

›Look externally: facial trauma, large incisors, beard, large tongue

›Evaluate 3-3-2 rule

›Mouth opening less than 3 finger-breadths

›Hyoid-to-chin distance less than 3 finger-breadths

›Thyroid notch-to-floor-of-mouth distance less than 2 finger-breadths

›Mallampati class III or IV

›Obstruction or obesity

›Stridor, muffled voice, drooling

›Neck mobility limitation

›Cervical collar, ankylosing spondylitis, rheumatoid arthritis

›Difficult bag-mask ventilation predictors (MOANS)

›Mask seal difficulty: beard, facial trauma, blood

›Obesity or obstruction

›Age >55 years

›No teeth (edentulous state impairs mask seal but can ease laryngoscopy)

›Stiff lungs or cervical spine immobilization limiting positioning

›Difficult supraglottic airway and cricothyrotomy predictors

›Restricted mouth opening or upper airway mass affecting supraglottic device placement

›Neck mass, hematoma, prior surgery, or radiation affecting cricothyrotomy access

Physiologic difficult airway assessment

›Vital sign screen immediately before drug administration

›SpO2 on the current oxygen delivery device

›Blood pressure and heart rate trend over the preceding 15 minutes

›Respiratory rate and pattern (Kussmaul respirations suggest severe acidosis)

›Bedside signs of right ventricular strain

›Jugular venous distension

04Differential Diagnosis/ddx27

Causes of peri-intubation hypotension and cardiac arrest

›Sedation and ventilation-related causes

›Induction-agent vasodilation and loss of sympathetic tone

›Most severe with propofol, least with etomidate and ketamine

›Positive pressure ventilation reducing preload

›Worsened by any PEEP or breath stacking

›Excessive sedative or opioid bolus dosing

›Occult pathology unmasked by induction

›Hemorrhagic or hypovolemic shock unmasked once sympathetic tone is lost

›Tension pneumothorax from positive pressure ventilation of a bullous or traumatic lung

›Anaphylaxis to the induction agent or neuromuscular blocker

›Cardiac tamponade decompensating with reduced venous return

›DOPES mnemonic for the acutely deteriorating intubated patient

›Displacement of the tube (esophageal or mainstem)

›Obstruction of the tube (mucus plug, kink, biting)

›Pneumothorax (tension)

›Equipment failure (disconnected circuit, ventilator malfunction, empty oxygen source)

›Stacked breaths (breath-stacking auto-PEEP in obstructive disease)

Failed airway vs failed oxygenation vs failed ventilation

›Failed intubation

›Inability to place the tube after best attempts by the most experienced operator

›Move to a rescue device or surgical airway per algorithm

›ICD-10 T88.4 (failed or difficult intubation) as the general procedural-complication code

›Failed oxygenation

›SpO2 falling despite bag-mask ventilation or a supraglottic device

›Highest-acuity failure mode; proceed to cricothyrotomy without delay (cannot intubate, cannot oxygenate)

›Failed ventilation after successful intubation

›Rising peak pressures, desaturation, or hypotension after tube placement

05Laboratory Tests/lt23

Labs that change induction and paralytic selection

›Serum potassium

›Baseline hyperkalemia (renal failure, missed dialysis, rhabdomyolysis) contraindicates succinylcholine

›Use rocuronium instead

›Point-of-care potassium when formal chemistry would delay a time-critical intubation

›Venous or arterial blood gas

›pH <7.2 identifies the severe-acidosis physiologically difficult airway

›Guides post-intubation ventilator rate matching, not induction drug selection

›Baseline PaCO2 sets the post-intubation ventilator target

›Renal function

›Creatinine and eGFR modestly prolong rocuronium duration and affect clearance of sedative infusions

›Hemoglobin and lactate

›Severe anemia lowers oxygen reserve and shortens safe apnea time

›Elevated lactate supports occult shock recognition before induction

Point-of-care and confirmatory testing

›Waveform capnography (end-tidal CO2)

›Confirms tracheal placement immediately after intubation

›Absence of a waveform after three ventilations indicates esophageal placement until proven otherwise

›Trended continuously post-intubation

›Sudden loss suggests dislodgement, disconnection, or cardiac arrest

›Point-of-care glucose

›Checked peri-intubation in any patient with altered mental status before induction

›Hypoglycemia mimics or worsens post-induction obtundation and is rapidly correctable

›Point-of-care blood gas post-intubation

›Confirms ventilator settings are matching physiologic need within 15 to 30 minutes of intubation

06Diagnostic Tests/dt45

Scoring Systems

›LEMON and MOANS bedside airway scores

›Predict anatomically difficult laryngoscopy and bag-mask ventilation

›Neither score predicts hemodynamic collapse, which is physiologic rather than anatomic

›HOp Killers framework

›Hypoxemia, hypotension, severe acidosis, right ventricular failure

›Each independently predicts peri-intubation arrest regardless of airway anatomy

›Richmond Agitation-Sedation Scale (RASS)

›Range -5 (unresponsive) to +4 (combative)

›Target 0 to -2 for most post-intubation patients

›Deeper targets (-3 to -5) reserved for specific indications, not default practice

›Confusion Assessment Method for the ICU (CAM-ICU)

›Validated delirium screen for mechanically ventilated patients

›Performed only when RASS is -3 or lighter; deeper sedation cannot be validly assessed for delirium

›Behavioral Pain Scale (BPS) and Critical-Care Pain Observation Tool (CPOT)

›Validated pain assessment tools for nonverbal, sedated, or paralyzed patients

›Facial expression, limb movement, and ventilator compliance components

MRI

›MRI role around RSI

›No acute role in the intubation decision itself

›Time and monitoring incompatibility with an unstable airway patient

›Post-stabilization indications

›Suspected cervical spine injury requiring clearance before positioning changes

›Anoxic brain injury characterization after a peri-intubation cardiac arrest

›Contraindications

›Hemodynamic instability requiring continuous intervention

›Non-MRI-compatible monitoring or infusion pumps without MRI-conditional equipment

07Disposition/dispo15

Post-intubation level of care

›ICU admission required after every emergency RSI

›Ventilator management, sedation titration, and hemodynamic monitoring require ICU-level nursing ratios

›ED boarding of an intubated patient still requires ICU-equivalent monitoring and staffing

›Ongoing reassessment in the ED while awaiting an ICU bed

›Sedation and analgesia continued and titrated, not held pending transfer

›Ventilator settings reassessed at least hourly with blood gas correlation

Transfer considerations for the intubated patient

›Secure the airway before transfer whenever feasible

›A physiologically or anatomically difficult airway should generally be secured locally rather than transferred unintubated

›Stabilize hemodynamics with vasopressor infusion, not repeated pushes, before departure

›Communication with the receiving facility

›Induction agent, paralytic, and doses given communicated explicitly

›Ventilator settings and most recent blood gas communicated

›Transfer-specific hazards

›Ambulance and aircraft vibration and altitude change affecting cuff pressure and oxygenation

›Sedation and analgesia supply confirmed for the full transfer duration before departure

08Treatment/t197

Pre-oxygenation and apneic oxygenation

›Standard pre-oxygenation

›Non-rebreather mask at 15 L/min for 3 minutes, or 8 vital capacity breaths in a cooperative patient

›Head-of-bed elevation 20 to 30 degrees or ramped position in obesity improves apnea tolerance

›Pre-oxygenation for shunt physiology

›Bag-valve-mask with a PEEP valve, or noninvasive ventilation, for patients who desaturate despite a non-rebreather mask

›Gentle bag-mask ventilation between induction and laryngoscopy reduces hypoxemia without increasing aspiration risk in critically ill adults

›Apneic oxygenation during the apneic period

›Nasal cannula at 15 L/min (or high-flow nasal cannula where available) left running through laryngoscopy

›Extends safe apnea time in patients with adequate FRC and lung compliance

›Benefit is less consistent in patients with significant shunt physiology or very poor FRC

›Adequate duration is not optional

›2 to 3 minutes of pre-oxygenation changes outcomes even in a patient who appears to need immediate laryngoscopy

Hemodynamic optimization before induction

›Fluid bolus before induction when hypovolemia is suspected

›500 mL to 1 L crystalloid bolus over 10 to 15 minutes if time and physiology allow

›Deferred or reduced in cardiogenic shock, right ventricular failure, or pulmonary edema, where fluid worsens congestion

›Push-dose vasopressor drawn up before induction regardless of the current blood pressure

›Phenylephrine 100 mcg IV push (range 50 to 200 mcg), repeat every 2 to 5 minutes

›Avoid as the sole agent when negative inotropy or bradycardia would be harmful

›Epinephrine 10 mcg IV push (range 5 to 20 mcg), repeat every 2 to 5 minutes

›Preferred when inotropic support is also needed

›Continuous vasopressor infusion started early rather than escalating pushes indefinitely

›Norepinephrine 0.05 to 1 mcg/kg/min IV, titrated to MAP >=65 mmHg

›First-line continuous agent for most peri-intubation shock physiology

Induction agent selection by physiology

›Etomidate

›Standard dose 0.3 mg/kg IV

›Onset 15 to 45 seconds

›Duration of action 5 to 15 minutes

›Hemodynamically neutral, with minimal effect on SBP and SVR

›Preferred agent for the failing right ventricle and for raised intracranial pressure requiring a stable MAP for cerebral perfusion pressure

›Adrenal suppression from a single induction dose

›Transient cortisol suppression is demonstrated, but a large randomized trial (KETASED) found no significant mortality difference between etomidate and ketamine for prehospital and ED RSI

›Some clinicians avoid single-dose etomidate in septic shock on theoretical grounds; ketamine is a reasonable alternative in that setting

›Dose reduction in shock is not required by most protocols given its hemodynamic neutrality, though some reduce to 0.2 mg/kg IV in profound shock

›Ketamine

›Standard dose 1.5 mg/kg IV (range 1 to 2 mg/kg); 4 mg/kg IM if no IV access

›Onset 45 to 60 seconds IV

›Duration of action 10 to 20 minutes

›Shock-dose reduction: 0.5 to 1 mg/kg IV in significant hypotension or shock

›Sympathomimetic effect (raises HR, BP, and cardiac output) is preserved in most patients, but catecholamine-depleted or chronically critically ill patients can show unmasked direct myocardial depression instead

›Bronchodilatory properties make it the preferred induction agent in status asthmaticus

›Raised intracranial pressure

›Older teaching that ketamine raises ICP is not supported in ventilated, sedated patients maintained at normocapnia; contemporary evidence supports its use in traumatic brain injury

›Right ventricular failure and pulmonary hypertension

›Some evidence of modestly increased pulmonary vascular resistance; etomidate is generally preferred when RV failure is the dominant physiology, but ketamine remains an acceptable second choice when hemodynamic stability outweighs this theoretical concern

›Propofol

›Standard dose 1.5 to 2 mg/kg IV

›Onset 15 to 45 seconds

›Duration of action 5 to 10 minutes

›Shock-dose reduction: 0.5 to 1 mg/kg IV, or avoided entirely in significant hypotension or shock

›Direct vasodilation and negative inotropy make it the least hemodynamically forgiving induction agent

›Useful when a rapidly reversible, short-acting agent is desired and hemodynamics are stable

›Bronchodilatory properties support use in status asthmaticus when hemodynamics allow

›Midazolam

›Induction dose 0.1 to 0.3 mg/kg IV

›Onset 2 to 3 minutes, slower and less predictable than the other three agents

›Duration of action 15 to 30 minutes after a single dose

›Not a preferred sole induction agent for RSI given delayed onset and hypotension risk

›Reserve as an induction agent only when the other three are unavailable or contraindicated

Paralytic selection and dosing

›Succinylcholine (depolarizing)

›Adult dose 1.5 mg/kg IV (range 1 to 2 mg/kg)

›Onset 45 to 60 seconds

›Duration of action 6 to 10 minutes

›Not dose-reduced for shock physiology; paralytic dosing is independent of hemodynamic status

›Fasciculations and a transient serum potassium rise of approximately 0.5 to 1 mmol/L occur even in patients without contraindications

›Rocuronium (nondepolarizing)

›RSI dose 1.2 mg/kg IV

›Onset 45 to 60 seconds, comparable to succinylcholine at this dose

›Duration of action 45 to 70 minutes

›Not dose-reduced for shock physiology; paralytic dosing is independent of hemodynamic status

›Preferred agent whenever any succinylcholine contraindication is present

›Sugammadex 16 mg/kg IV reverses rocuronium within 2 to 3 minutes if immediate reversal is required for a failed airway rescue plan

›Choosing between the two paralytics

›Succinylcholine preferred when rapid spontaneous return of ventilation is valued and no contraindication exists

›Rocuronium preferred with any contraindication to succinylcholine, or when prolonged paralysis is desired (difficult airway with planned prolonged control, post-intubation NMB)

Succinylcholine contraindications and the safe window

›Hyperkalemia

›Known or suspected baseline hyperkalemia (renal failure, missed dialysis, rhabdomyolysis, tumor lysis)

›Even the expected 0.5 to 1 mmol/L rise can precipitate a lethal arrhythmia on top of an already elevated potassium

›Burns and crush injury

›Safe within the first 24 to 48 hours after injury

›Contraindicated beginning approximately 3 to 5 days after injury and persisting for up to 6 months to 2 years

›Extrajunctional acetylcholine receptor upregulation causes massive, unpredictable potassium efflux

›Denervation and neuromuscular disease

›Stroke, spinal cord injury, prolonged immobilization, Guillain-Barre syndrome

›Safe within the first 24 to 48 hours after the denervating event

›Contraindicated beginning approximately 3 to 5 days after the event and persisting for up to 6 months to 2 years

›Myasthenia gravis, muscular dystrophy, and other primary myopathies

›Unpredictable and potentially severe hyperkalemic response; avoid regardless of timing since injury

›Malignant hyperthermia

›Personal or family history is an absolute contraindication

›Triggers a hypermetabolic crisis; dantrolene 2.5 mg/kg IV is the treatment if triggered

›ECG changes of succinylcholine-induced hyperkalemia to recognize immediately

›Peaked T waves progressing to widened QRS and a sine-wave pattern

›Treat as hyperkalemic cardiac arrest: calcium, insulin/dextrose, bicarbonate, and hyperventilation

Peri-intubation iatrogenic harms checklist

›Intubation itself

›Laryngoscopy triggers a sympathetic surge that can worsen aortic dissection, raised ICP, and active ischemia

›A rapid-onset opioid (fentanyl 1 to 3 mcg/kg IV) as a co-induction agent blunts this response when time allows

›Positive pressure ventilation drops preload and can precipitate arrest in hypovolemia and right ventricular failure

›Sedation

›Undersedation with ongoing paralysis produces awareness while paralyzed, a preventable and traumatic harm

›Oversedation causes hypotension, delirium, and delayed ventilator liberation

›Benzodiazepine-based sedation is associated with more delirium than propofol- or dexmedetomidine-based strategies and is not the default choice

›Fluid loading

›Harmful in cardiogenic shock, right ventricular failure, and pulmonary edema, where it worsens congestion

›Required before induction in hypovolemic and septic shock to blunt induction-related hypotension

›Oxygen

›Generous, even excessive, oxygen is appropriate during pre-oxygenation and the apneic period regardless of baseline status

›Sustained hyperoxia (targeting SpO2 100%) after the airway is secured is not benign; target SpO2 94 to 98% post-intubation in most patients, with individualized lower targets in chronic hypercapnic disease

›Vasopressors

›Required as push-dose or infusion before and during induction in any hemodynamically marginal patient

›Pure alpha-agonist (phenylephrine) as a sole, sustained agent is harmful in cardiogenic shock via reflex bradycardia and no inotropic support

›Mechanical circulatory support (including intra-aortic balloon pump)

›Not initiated as part of routine RSI, but relevant when the physiologically difficult airway is caused by cardiogenic shock

›IABP has not shown a mortality benefit in AMI-related cardiogenic shock and is not a substitute for correcting peri-intubation hemodynamics

›Anticoagulation and fibrinolysis

›Recently anticoagulated or fibrinolysed patients (massive PE, ischemic stroke) require atraumatic technique

›Video laryngoscopy, avoidance of nasal intubation and blind nasogastric placement, and minimizing attempt number all reduce bleeding harm

›Analgesia

›Untreated pain drives the sympathetic surge and increases sedative requirement; analgesia-first sequencing addresses this at the source

›Opioid-induced hypotension in shock is dose- and rate-related; give fentanyl slowly and in reduced doses rather than omitting analgesia entirely

Post-intubation analgesia-first sedation

›Analgesia-first (analgosedation) sequencing

›Treat pain before adding or escalating a sedative; endotracheal tubes, positioning, and procedures are painful even when the patient cannot report it

›PADIS 2018 guideline supports an analgesia-first or analgesia-based approach over routine sedative-first strategies

›Fentanyl (preferred first-line analgesic)

›Bolus 0.5 to 1 mcg/kg IV, may repeat every 30 to 60 minutes

›Onset 1 to 2 minutes, duration 30 to 60 minutes per bolus

›Continuous infusion 25 to 200 mcg/hr IV in a typical adult, titrated to pain scale and comfort

›Minimal histamine release and hemodynamic stability make it preferred over morphine in shock and in bronchospastic disease

›Morphine (alternative)

›Bolus 2 to 4 mg IV, may repeat every 1 to 2 hours

›Histamine release can worsen hypotension and bronchospasm; avoid as first choice in shock and in status asthmaticus

›Pain assessment in the nonverbal intubated patient

›Behavioral Pain Scale or Critical-Care Pain Observation Tool performed at least every 4 hours and with any procedure

›Self-report is used whenever the patient can reliably communicate, even while intubated

Sedation depth targets and assessment

›Default target: light sedation

›Richmond Agitation-Sedation Scale (RASS) target 0 to -2 for most mechanically ventilated patients

›Reassessed at least every 4 hours and after any dose change

›Light sedation is associated with shorter ventilator duration and ICU stay compared with routine deep sedation

›Propofol (preferred continuous sedative when hemodynamics allow)

›Infusion 5 to 50 mcg/kg/min IV, start low and titrate to the RASS target

›No loading bolus required for maintenance sedation; the induction dose already given is sufficient

›Propofol-related infusion syndrome risk

›Risk rises with doses above 4 mg/kg/hr sustained beyond 48 hours

›Monitor triglycerides, creatine kinase, lactate, and ECG (Brugada-like pattern) every 48 to 72 hours on a prolonged high-dose infusion

›Dexmedetomidine (alternative, especially to facilitate extubation or reduce delirium)

›Infusion 0.2 to 0.7 mcg/kg/hr IV (up to 1.5 mcg/kg/hr in some protocols)

›No loading bolus in critically ill patients; bolus dosing causes hypotension and bradycardia

›Preserves a more arousable sedation level than propofol or benzodiazepines

›Midazolam (reserve, not default)

›Infusion 0.02 to 0.1 mg/kg/hr IV

›Context-sensitive half-life lengthens substantially with infusion duration, delaying awakening

›Associated with more delirium than propofol- or dexmedetomidine-based sedation

›Reserve for seizure control, alcohol withdrawal, or when the other agents are contraindicated

›Delirium monitoring

›Confusion Assessment Method for the ICU (CAM-ICU) performed at least once per nursing shift when RASS is -3 or lighter

›Deeper sedation precludes a valid delirium assessment until the patient is lightened

Daily sedation interruption and delirium prevention

›Daily sedation interruption ("sedation vacation")

›Pause the continuous sedative infusion daily and reassess the patient off sedation before restarting at a reduced rate if still indicated

›The original trial (Kress et al, 2000) showed shorter duration of mechanical ventilation and ICU stay

›Pairing interruption with a spontaneous breathing trial (Girard et al, the ABC trial, 2008) improves outcomes further than either alone

›Contraindications to daily interruption

›Active neuromuscular blockade in progress

›Ongoing hemodynamic or respiratory instability that would be unsafe to unmask

›Active seizure control or therapeutic hypothermia requiring continuous deep sedation

›Non-pharmacologic delirium prevention bundle

›Early mobilization when hemodynamically and respiratorily feasible

›Sleep-wake cycle preservation: minimize nighttime interruptions, natural light exposure by day

›Early family presence and reorientation

›Hearing aids and glasses returned to the patient as soon as feasible

Neuromuscular blockade after intubation

›Genuine indications for continued paralysis after intubation

›Severe patient-ventilator dyssynchrony not resolved by adequate sedation and ventilator adjustment

›Refractory status asthmaticus with life-threatening dyssynchrony or breath stacking

›Therapeutic hypothermia with shivering not controlled by sedation alone

›Refractory intracranial hypertension with sedation-resistant coughing or straining

›Not a substitute for adequate sedation and analgesia

›Paralysis must never be used to mask undertreated pain or agitation; sedation and analgesia are titrated first and continued underneath any neuromuscular blockade

›A large trial (ROSE, 2019) found no mortality benefit from a strategy of routine early continuous paralysis with higher PEEP and lighter sedation over light sedation without routine paralysis in moderate-to-severe ARDS, reversing the more selective benefit suggested by an earlier trial (ACURASYS, 2010) of 48-hour paralysis in severe ARDS

›Agents and monitoring

›Cisatracurium infusion 1 to 3 mcg/kg/min IV, or a vecuronium or rocuronium infusion as alternatives

›Train-of-four monitoring targeting 1 to 2 twitches of 4, reassessed at least every 4 hours

›Continuous deep sedation (RASS -4 to -5) mandatory for the entire duration of any continued paralysis

›Minimize duration

›Reassess the ongoing indication for neuromuscular blockade at least daily; discontinue as soon as the triggering physiology resolves

›Prolonged neuromuscular blockade combined with corticosteroids increases critical illness myopathy risk

Initial ventilator settings by pathology

›General starting point

›Tidal volume 6 to 8 mL/kg ideal body weight, respiratory rate 12 to 16/min, PEEP 5 cm H2O, FiO2 titrated to SpO2 94 to 98%

›See the dedicated mechanical ventilation topic for full ventilator management detail

›Status asthmaticus and severe obstructive disease

›Low respiratory rate 10 to 12/min, long expiratory time, permissive hypercapnia, low or zero extrinsic PEEP

›Severe metabolic acidosis (DKA, salicylate toxicity)

›Initial minute ventilation set to match or exceed the patient's pre-intubation compensatory minute ventilation

›Under-ventilation immediately post-intubation is a described mechanism of peri-intubation arrest in this population

›Right ventricular failure and pulmonary hypertension

›Minimize PEEP and plateau pressure to avoid further increasing right ventricular afterload

›Avoid hypoxia, hypercapnia, and acidosis, each of which raises pulmonary vascular resistance

›Raised intracranial pressure

›Target normocapnia (PaCO2 35 to 40 mmHg); avoid both hyperventilation-induced ischemia and hypoventilation-induced ICP elevation

›Head-of-bed elevation 30 degrees maintained after intubation

09Special Populations/sp55

Pregnancy

›Airway physiology in pregnancy

›Failed intubation rate historically reported around 1 in 250 to 300 obstetric general anesthetics, higher than the general population's approximately 1 in 2000

›Airway edema, mucosal engorgement, weight gain, and breast enlargement contribute

›Reduced functional residual capacity and increased oxygen consumption shorten safe apnea time

›Pre-oxygenation and apneic oxygenation are even more critical than in nonpregnant patients

›Aortocaval compression in the supine position reduces venous return

›Left lateral tilt or manual uterine displacement maintained through induction

›Drug selection in pregnancy

›Succinylcholine and rocuronium are both considered safe, with minimal clinically significant placental transfer at RSI doses

›Etomidate, propofol, and ketamine are all used; ketamine may be preferred in hemorrhage-associated hypotension for its hemodynamic support

›Aspiration risk is elevated throughout pregnancy from delayed gastric emptying and reduced lower esophageal sphincter tone

›Cricoid pressure is no longer uniformly recommended; apply only if it does not worsen the laryngoscopic view

›Fetal considerations

›Continuous fetal heart rate monitoring when gestation is viable and monitoring does not delay maternal stabilization

›Maternal SpO2 and blood pressure targets take priority; fetal status follows maternal physiology

Geriatric

›Reduced physiologic reserve

›Shorter safe apnea time from reduced FRC and higher closing capacity

›Reduced hepatic and renal clearance prolongs the effect of most induction agents and sedatives

›Dosing modifications

›Reduce induction agent doses further even without overt hypotension

›Etomidate 0.2 mg/kg IV, propofol 0.5 to 1 mg/kg IV, or ketamine 0.5 to 1 mg/kg IV are reasonable reduced starting points

›Paralytic dosing is not reduced by age, matching the general rule that paralytic dose is independent of physiology

›Post-intubation sedative and opioid infusions started at the low end of the adult range and titrated slowly

›Airway and comorbidity considerations

›Edentulous state impairs bag-mask seal but can ease laryngoscopy

›Cervical spine arthritis and limited neck extension increase anatomic difficulty

10Background/b34

Epidemiology

›RSI is the predominant intubation method in emergency medicine

›Used in the large majority of adult ED intubations in registry data (National Emergency Airway Registry)

›First-pass success rates of approximately 85 to 90% are reported in contemporary registries, improved with routine video laryngoscopy

›Peri-intubation complications

›Post-intubation hypotension is reported in roughly a quarter to nearly half of ED and ICU intubations depending on definition and population

›Peri-intubation cardiac arrest is reported in approximately 1 to 4% of emergency intubations

›Post-intubation sedation gaps

›Delayed initiation of post-intubation sedation and analgesia is repeatedly documented in ED cohorts, with meaningful proportions of patients receiving no sedative for 30 minutes or longer after paralysis

›The awake-paralyzed interval this produces is a recognized, preventable harm

Pathophysiology

›Sympathetic surge with laryngoscopy

›Direct laryngoscopy stimulates a transient catecholamine surge raising heart rate and blood pressure

›Clinically relevant in aortic dissection, active ischemia, and raised intracranial pressure

›Apnea and the oxyhemoglobin dissociation curve

›Desaturation is slow while SpO2 remains above the curve's steep portion, then falls precipitously below approximately 90%

›Explains why pre-oxygenation to a high starting SpO2 meaningfully extends safe apnea time

›Positive pressure ventilation physiology

›Positive intrathoracic pressure reduces venous return and increases right ventricular afterload

›The mechanism underlying the "three hits" of peri-intubation hemodynamic collapse

›Neuromuscular blockade pharmacology

›Depolarizing blockade (succinylcholine): sustained depolarization of the motor endplate causes fasciculation followed by flaccid paralysis

›Extrajunctional receptor upregulation after denervation or prolonged immobility converts this into a massive, unpredictable potassium efflux

›Nondepolarizing blockade (rocuronium): competitive antagonism at the acetylcholine receptor without depolarization

›No fasciculation and no associated potassium shift

Therapeutic Considerations

›Evidence for pre-oxygenation and apneic oxygenation

›Bag-mask ventilation between induction and laryngoscopy reduces hypoxemia without increasing aspiration risk in critically ill adults (PreVent trial)

11Patient Discharge Instructions/pdi21

copy discharge instructions

›After a breathing tube and ventilator: what to expect once discharged home

›Sore throat or a hoarse voice for several days to weeks after the tube is removed is common and usually self-limited

›Warm fluids and voice rest help; hoarseness persisting beyond several weeks should be evaluated

›Memory gaps, vivid or frightening dreams, or trouble concentrating are common after critical illness and sedation

›These usually improve over weeks to months; tell your doctor if they persist or worsen

›Muscle weakness and fatigue after a prolonged ICU stay are expected and improve gradually with activity and, where arranged, physical therapy

›Warning signs requiring return to the emergency department

›New or worsening shortness of breath

›Stridor (harsh, high-pitched breathing sound) or difficulty swallowing

›Fever with productive cough after a prolonged intubation, raising concern for aspiration or ventilator-associated pneumonia

›New chest pain or palpitations

›Confusion, severe anxiety, or intrusive memories interfering with daily function

›Follow-up instructions

›Primary care and any relevant specialist follow-up (cardiology, pulmonology, neurology) arranged before discharge based on the reason for intubation

›Screening for post-intensive care syndrome and post-traumatic stress symptoms at follow-up when a prolonged ICU stay occurred

Family and caregiver communication during intubation and sedation

›What to expect while a family member is sedated and on a ventilator

›Sedation is adjusted daily; brief periods of lighter sedation are a planned part of care, not a sign of instability

›The care team can explain the current sedation goals and expected timeline at any point

›Consent and decision-making in an emergency

›Emergency intubation is performed without delay when the airway or breathing is immediately at risk, before a full consent discussion is possible

›Goals-of-care and advance directive discussion is prioritized as soon as the patient is stabilized

12References/r25

Guidelines and key sources

›Difficult Airway Society (DAS) 2015 Guidelines for management of unanticipated difficult intubation in adults

›Frerk C et al. British Journal of Anaesthesia. 2015

›American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

›Apfelbaum JL et al. Anesthesiology. 2022

›PADIS 2018 Clinical Practice Guidelines for Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult ICU Patients

›Devlin JW et al. Critical Care Medicine. 2018

›Manual of Emergency Airway Management (textbook, current edition)

›Walls RM, Murphy MF

›National Emergency Airway Registry (NEAR) project

›Brown CA, Walls RM et al. Multiple publications, Annals of Emergency Medicine

Landmark trials and pharmacology reviews

›Preoxygenation and apneic oxygenation

›Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. 2012

›Casey JD et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults (PreVent trial). New England Journal of Medicine. 2019

›Semler MW et al. Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill. American Journal of Respiratory and Critical Care Medicine. 2016

›The physiologically difficult airway

›Mosier JM et al. The Physiologically Difficult Airway. Western Journal of Emergency Medicine. 2015

›Heffner AC et al. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013

›Induction agent evidence

›Jabre P et al. Etomidate versus Ketamine for Rapid Sequence Intubation in Acutely Ill Patients (KETASED trial). Lancet. 2009

›Sedation and delirium evidence

›Kress JP et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine. 2000

›Girard TD et al. Efficacy and safety of a paired sedation and ventilator weaning protocol (ABC trial). Lancet. 2008

›Neuromuscular blockade evidence in ARDS

›Papazian L et al. Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome (ACURASYS trial). New England Journal of Medicine. 2010

›National Heart, Lung, and Blood Institute PETAL Clinical Trials Network (Moss M et al). Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome (ROSE trial). New England Journal of Medicine. 2019

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed September 13, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.