1. Prepare equipment and position patient as appropriate:
    1. Pre-intubation capnography is the standard of care when utilizing BVM to assist ventilations pre-RSI.
    2. Pre-oxygenate with 100% FiO2.
    3. Back–up plan: LMA, anesthesia, and/or surgical airway.
  2. For "Crash Airways" proceed to Step 6
    1. A patient with a GCS of 8 or less, a low oxygen saturation, Apnea or significant tachypnea and has not responded to basic methods of ventilation and oxygenation or if clinically indicated.
  3. Consider pre-medication as appropriate:
    1. Consider Atropine for patients < 1 year:  0.02 mg/Kg IVP (minimum dose 0.1 mg)
  4. Provide analgesia with Fentanyl: (See Pain/sedation protocol.)
  5. Induce unconsciousness with Etomidate 0.1-0.3 mg/Kg IVP or Ketamine 1-2 mg/kg IVP or versed 0.1-0.2 mg/kg.
  6. Induce paralysis with: **Ensure ventilation prior to paralysis.
    1. Rocuronium (Zemuron)
      • 1 mg/Kg IVP (Up to a max dosage of 100mg) OR
    2. cis-atracurium (Nimbex):
      • < 12 years: 0.1 mg/Kg IVP
      • > 12 years: 0.2 mg/Kg IVP

Consider risk of paralytics if:

  • Unable to bag-mask ventilate
  • Known difficult intubation.
  • Mediastinal mass
  • Other contraindications

ETT placement will be confirmed using CXR and continuous waveform capnography.


  1. Sedation, analgesia and neuromuscular blockade may be utilized as necessary to ensure a secure airway and for the comfort of the patient.
  2. Appropriate sized bag-valve-mask available for accidental extubation.
  3. Provide gastric decompression.
  4. Sedation/Analgesia: (see pain/sedation protocol)
    • Midazolam (Versed) may be repeated as necessary based on clinical response
    • Fentanyl may repeat as necessary based on clinical response
  5. Neuromuscular blockade for post-intubation paralysis with cis-atracurium (Nimbex) or Rocuronium (Zemuron)

All intubated patients will have continuous waveform capnography post intubation.


  1. Hsiao AL, Baker MD. Childhood Resuscitation. Pediatric Emergency Medicine Secrets. Second ed. Mosby; Philadelphia, PA. 2008. pp. 9-19.
  2. Yamamoto LG. Emergency Airway Management – Rapid Sequence Intubation. Textbook of Pediatric Emergency Medicine. Fifth ed. Lippincott, Williams & Wilkins; New York, NY. 2006. pp. 81-92.

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