Increased respiratory rate > 20 rpm

SPO2 < 90%

Increased work of breathing characterized by use of accessory muscles

Presence of abnormal breath sounds including wheezing, crackles, rhonchi, or diminishment

May be present including tachycardia, hypertension, hypotension, fever, or altered mental status

Tripod position is when a patient is sitting over the bed leaning forward, supporting their upper body with their hands on the knees or another surface. This helps accessory muscles breath more easily, but can be an ominous sign to someone who is in respiratory distress. Think COPD!

Etomidate can cause myoclonus to occur, which is brief and harmless, but can be mistaken for a seizure.

Etomidate can cause adrenal suppression for 12-24 hours after the injection. This could potentially impact hemodynamic stability (blood pressure), mainly in patients who are at risk such as those with pre-existing adrenal insufficiency or severe sepsis.

Patients with severe sepsis who are intubated with etomidate and become hypotensive despite fluids and a vasopressor should be given a 1x dose of hydrocortisone 100mg IV.

Etomidate doesn’t cause HF, but patients with pre-existing HF may have exacerbated underlying myocardial dysfunction after administration.

Increased respiratory rate > 20 rpm

Versed can cause a decrease in Mean Arterial Pressure (MAP) by 10-25%. This means Versed should generally be avoided in hypotensive patients or those at risk for hypotension (severe sepsis, trauma, etc).

Ketamine increases the risk of laryngospasm, especially in those with history of upper respiratory disease or asthma. This is because ketamine does not suppress pharyngeal and laryngeal reflexes. In this case, it can be helpful to use fentanyl with it

Ketofol is the combination of ketamine and fentanyl. This can cause analgesia, sedation, and amnesia, and can be a good choice for patients with severe bronchospasm.

Ketamine causes increased stimulation of the sympathetic nervous system, releasing catecholamines leading to tachycardia, hypertension, increased myocardial demand, and even possible cardiac arrhythmias.

This can be beneficial in patients who are hypotensive, but dangerous for those with active cardiac disease or aortic dissection.

Ketamine can cause an “emergence phenomenon” primarily when used for procedural sedation. This is when the patient may experience vivid and/or disturbing dreams as they wake up. Hallucinations and frank delirium may occur postoperatively up to 24 hours. 

This usually does not happen with patients who are intubated and sedated for over 24 hours.

Make sure your specific state and facility allow RNs to give IV boluses of propofol, and if so, make sure the provider is always at the bedside. Since propofol causes deep sedation, it may not be within your scope as a nurse to push it. Seems silly, but always protect your license!

Propofol has a blood pressure lowering effect, which can decrease the MAP by 10%, but sometimes even ≥ 30%.

Use caution if the patient has a borderline low pressure or baseline MAP of 60-70 mmHg.

Patients at risk for hypotension include severe sepsis, trauma, severe aortic stenosis, etc.

Propofol can cause bradyarrythmias to occur. This is more common with high doses, prolonged duration, and concurrent medications like beta-blockers, paralytics, and opioids. Patients with a history of cardiac disease are at increased risk.

QT prolongation can predispose your patient to dangerous ventricular arrhythmias like Torsades de Pointes and VFIB. This is more common with:

• High propofol doses
• Elderly patients
• Structural heart disease
• Congenital Long QT
• QT prolonging medications
• Electrolyte Disturbances

Anaphylaxis is rare with Propofol but can occur, usually within 5-10 minutes after infusion. Those with a history of soybean or egg allergy are probably fine to take it.

Allergy to soybeans or egg used to be a contraindication for receiving propofol, but newer formulations of the drug rarely produce a reaction and are likely safe

Propofol is a lipophilic fatty solution which contains triglycerides. Infusion can lead to elevations in triglycerides and lipase, which usually occurs 2-4 days after initiation. This can lead to pancreatitis, especially in those who are already at risk.

PRIS stands for Propofol Infusion Syndrome. PRIS is rare but deadly. When occurs, the patient suffers from acute refractory bradycardia which may lead to asystole, and also may have:

• severe metabolic acidosis,
• cardiovascular collapse,
• rhabdomyolysis
• hyperlipidemia
• renal failure
• hepatomegaly

This is more common with high doses (>4mg/kg/hr) and long duration of use (>48 hours).

Etomidate

Propofol or Etomidate

Propofol or Ketamine (+/- fentanyl)

Etomidate +/- Fentanyl

Etomidate 0.15mg/kg or ketamine 1mg/kg

Patients with MG are resistant to Sux, so should be given 2mg/kg

Sux commonly causes fasciculations of the muscles prior to causing full paralysis.

This may increase ICP and stimulate emesis leading to aspiration.

A metabolite of Sux can stimulate muscarinic receptors to release acetylcholine, producing bradycardia of the sinus node. This can be treated with atropine.

ROC can increase peripheral vascular resistant and cause a temporary increase in BP. It can also cause transient hypotension in some people. 

ROC can cause temporary tachycardia for about 5 minutes.

ROC may worsen pulmonary HTN, leading to right-sided heart failure in those who are predisposed.

Other non-depolarizing paralytics include Vecuronium and Pancuronium, but these are not used as often.

Vecuronium, shortened to “VEC”, is not used as frequently, as it has a longer onset of action – around 3 minutes. This can be reduced with a smaller “priming” dose.

To prepare the patient for RSI intubation, make sure they are positioned in the “sniffing” position, supine with their neck flexed. Placing a towel between their head and neck can help.

Make sure the patient is getting hyper-oxygenated at the same time, usually with a Non-rebreather or a Bag-valve mask at 100%.

Respiratory therapists are often in charge of airway along with the Provider.

Place the patient on the monitor including telemetry, continuous pulse ox, and end-tidal CO2 if possible.

Explain the procedure to the patient and ensure informed consent is obtained, either written or verbal. Written is often not able to be obtained due to the emergent nature of many intubations.

If the patient is altered, ensure there is no DNR or DNI order form or POLST. 

If using a BVM hooked up to 100% oxygen, make sure you are squeezing the BVM with each spontaneous breath to ensure the valve opens and the oxygen is given to the patient!

Bring the code cart at the bedside. You don’t necessarily need to hook up the defibrillation pads, but always follow facility protocol.

Most of the equipment needed will be found in the Airway drawer, usually one fo the last drawers.

The equipment needed for the actual intubation will be:

• Laryngoscope
• ET tube
• Stylet
• 10cc syringe
• Suction Tubing & Yankauer
• ETCO2 or CO2 detector
• Stethoscope
• Bag-valve mask

Ask the Provider which size ET tube they’ll want, which is often 7.0 for females, and 8.0 for males.

The stylet will need to be placed inside the ET tube, which is usually cuffed. This will be removed once the Provider gets the tube in the right spot.

The Provider will give you a verbal order for which sedative(s) and paralytic they want.

Verbally clarify the name and dose, and begin to draw up the medications. You may need to grab these medications from an “RSI kit” in the Accudose, or they may be located in your code cart.

Usually one of the nurses will assume the “medicine” responsibility while the others are preparing the patient and equipment.

Some medications will require reconstitution. This means you may need to mix saline with powdered medication to make a solution. Verify the final doses/amounts with another nurse.

Make sure to accurately label each, so you don’t mix up the sedative and the paralytic!

Once everyone is ready for the intubation, wait for the Provider’s verbal “ok” to give the medications, and administer the medications as above. Most are given quickly over 5-10 seconds. 

First the sedative, then once the patient has decreased LOC and you get the next verbal OK from the Provider, administer the paralytic.

RT should be bagging the patient at this time until the Provider is ready for the intubation. This is usually within 30-60 seconds after administering the paralytic.

Your main job is now done, and now you just watch the intubation procedure and monitor the patient, following any verbal orders that are given.

The Provider will place the ET tube between the vocal cords, typically 21cm deep in women and 23cm in men. This is measured at the teeth.

Immediately after intubation, the tube needs to be verified. This is verified in multiple ways.

First, a CO2 detector may be attached to the ET tube. Observing color change from purple to yellow indicates CO2.

If the patient is hooked up to an ETCO2, with each BVM breath, you should see normal CO2 levels near 35-45 mmHg.

Additionally, someone should listen to all breath sounds listening for equal breath sounds.

Lastly, the patient should have a portable CXR ordered to verify the placement. The radiologist may recommend pulling out or pushing deeper x amount of cm.

Now the patient is successfully intubated. Your main job now is keeping the patient sedated so that the Ventilator can do its job and breath for the patient.

This usually involves a continuous titratable drip, often propofol. The patient may also require additional sedatives, analgesics, and sometimes further paralytics.

Of course, make sure to chart everything and continue to monitor the patient’s vital signs.

If in the ER or Med-Surg, your goal should be to get that patient admitted/transferred ASAP.

This is when the ET tube is in the esophagus instead of the trachea. This becomes obvious when verifying placement.

When it occurs, the ET tube will be completely removed and the Provider will re-insert the tube with another attempt.

An OG or NG to suction should be placed in all patients after intubation to decompress the stomach to prevent emesis and to decrease intrathoracic pressure.

A foley should also be placed.

If the ET tube is placed slightly too deep, it will often go into the Right Mainstem Bronchus of the right lung. This is because it is more vertical than the left.

If left, the patient may have signs of hypoxemia and worsening respiratory status, and if not fixed can cause barotrauma, pneumothorax, and hemothorax.

Breath sounds should be equal throughout the lobes, but a CXR will need to be done to verify this isn’t the case. 

Treatment involves pulling out the ET tube per radiologists recommendations, which the Provider should do.