Airway, Drug Assisted
(OPTIONAL)
Indications for Drug Assisted AIrway Protocols AR 1, 2, and 3
Procedure will remove
Failure to protect the airway should be utilized together
patient s protective
and/or (even if agency is not using
airway reflexes and
Unable to oxygenate Drug Assisted Airway
ability to ventilate.
and/or Protocol) as they contain
Unable to ventilate useful information for airway
You must be sure of
and/or management.
your ability to intubate
Impending airway compromise
before beginning this
procedure.
Preoxygenate 100% O2
IV / IO Procedure Must have two (2)
A Paramedics on scene
(preferably 2 sites)
Assemble Airway Equipment
P Suction equipment
Alternative Airway Device
Airway Management
Ketamine 1.5 - 2 mg/kg IV / IO
Hypoxic Or
Hypotension Or YES P Airway Management + Dangerously
Airway Respiratory Protocol Section
Dangerously Combative? Combative
Ketamine 300 – mg IM
Ketamine 1.5 - 2 mg/kg IV / IO
NO
Correct Hypoxia and / or Hypotension
Etomidate 0.3 mg/kg IV / IO
Or Adult Airway
Ketamine 1.5 - 2 mg/kg IV / IO Adult Failed Airway
May repeat x 1 Protocol(s) AR 1, 2
as indicated
Succinylcholine 1.5 mg / kg IV/ IO
Or Hypotension / Shock
P Rocuronium 1 mg kg IV / IO Protocol AM 5
(if Succinylcholine contraindicated) as indicated
May repeat x 1
Intubate trachea
Placement Verified
Continuous Capnography
Consider Restraints Physical Procedure
P Consider Gastric Tube Insertion Procedure
Awakening or Moving
NO
after intubation
Red Text
YES are the key
performance indicators
Exit to used to evaluate
Post-intubation / protocol compliance.
BIAD Management
Protocol AR 8 An Airway Evaluation
Form must be
completed on every
patient who receives
Rapid Sequence
Intubation.
Notify Destination or
Contact Medical Control
Revised AR 3
01/01/2017 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS
Airway, Drug Assisted
(OPTIONAL)
Airway Respiratory Protocol Section
Pearls
Agencies must maintain a separate Performance Improvement Program specific to Drug Assisted Airway.
See Pearls section of protocols AR 1 and 2.
This procedure requires at least 2 Paramedics. Divide the workload – ventilate, suction, cricoid pressure, drugs, intubation.
Patients with hypoxia and/or hypotension are at risk of cardiac arrest when a sedative and paralytic medication are administered.
Hypoxia and hypotension require resuscitation and correction prior to use of these combined agents. Ketamine allows time for
appropriate resuscitation to occur during airway management.
This protocol is only for use in patients who are longer than the Broselow-Luten Tape.
Ketamine may be used during airway management of patients who FIT on the Broselow-Luten Tape with a DIRECT, ONLINE
MEDICAL ORDER, by the system MEDICAL DIRECTOR OR ASSISTANT MEDICAL DIRECTOR ONLY.
KETAMINE:
Ketamine may be used with and without a paralytic agent in conjunction with either a OP, NP, BIAD or endotracheal tube.
Ketamine may be used during the resuscitation of hypoxia or hypotension in conjunction with airway management. Once hypoxia
and hypotension are corrected, use of a sedative and paralytic can proceed if indicated.
Ketamine may be used in the dangerously combative patient requiring airway management IM. IV / IO should be established as
soon as possible.
Ketamine may NOT be used for purposes of sedation only – it must be used only during airway management procedures.
Continuous Waveform Capnography and Pulse Oximetry are required for intubation verification and ongoing patient monitoring,
though this is not validated and may prove impossible in the neonatal population (verification by two (2) other means is
recommended in this population.)
Before administering any paralytic drug, screen for contraindications with a thorough neurologic exam.
If First intubation attempt fails, make an adjustment and try again: (Consider change of provider in addition to equipment)
Different laryngoscope blade Change cricoid pressure; No longer routinely recommended and may worsen your view.
Different ETT size Align external auditory canal with sternal notch / proper positioning.
Change head positioning Consider applying BURP maneuver (Back [posterior], Up, and to patient s Right)
Paramedics / AEMT should consider using a BIAD if oral-tracheal intubation is unsuccessful.
During intubation attempts use External Laryngeal Manipulation to improve view of glottis.
Protect the patient from self-extubation when the drugs wear off. Longer acting paralytics may be needed post-intubation.
Drug Assisted Airway is not recommended in an urban setting (short transport) when able to maintain oxygen saturation
Consider Naso or orogastric tube placement in all intubated patients to limit aspiration and decompress stomach if needed.
DOPE: Displaced tracheostomy tube / ETT, Obstructed tracheostomy tube / ETT, Pneumothorax and Equipment failure.
Revised AR 3
01/01/2017 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS
