Rapid-Sequence Induction in the Adult ED Patient with Suspected Head Injury
1. Assemble staff, such as ED attending, nurse, respiratory therapist.
2. Continuously monitor blood pressure, electrocardiogram, Sp02.
3. Consult anesthesia if airway problems anticipated such as facial trauma, high index of suspicion for C-spine fracture, airway trauma, or edema.
4. Prepare equipment necessary (suction, endotracheal tube, laryngoscope, ambu bag, mask, oral/nasal airways).
5. Examine airway, check anatomy, be prepared to hand-ventilate or perform a surgical cricothyroidotomy.
6. Pre-oxygenate patient with 100% 02.
7. Lidocaine 1 mg/kg IV push (preferably one to two minutes before induction).
8. Ensure C-spine immobilization.
9. Etomidate 0.3 mg/kg IV.
10. Apply cricoid pressure.
11. Administer rocuronium 0.9 mg/kg IV.
12. Await full paralysis (up to two minutes); check eyelid reflex/jaw.
13. Maintain in-line C-spine immobilization.
14. Intubate orally.
15. Confirm endotracheal tube position with end tidal CO2 monitor or Easycap.
16. Release cricoid pressure.
17. Consider long-term paralysis with Pancuronium 0.1 mg/kg and sedation with midazolam (Versed) 0.2 mg/kg IV or lorazapam (Ativan) 0.5-2 mg/IV.
Source: Rhode Island Hospital, Providence.
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