Airway Intervention / Intubation

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Airway equipment

CUFFED Endotracheal Tube Size
• Cuffed generally preferred unless neonate
7.5 mm
UNCUFFED Endotracheal Tube Size
• Cuffed generally preferred unless neonate
8.0-8.5 mm
Laryngoscope Blade
3 Mac
Glidescope VL Blade Size
Size 4
Endotracheal Tube Depth
• appropriate endotracheal tube depth should be confirmed by Chest X-Ray as soon as feasible.
20.0 cm
LMA
Size 5
I-gel Airway
Size 4
King LTS Airway
Size 4
O₂ Mask
Adult
Oral Airway
Adult • 90 mm • Size 4
NP Airway
32 french
BVM (Bag-Valve-Mask)
Adult (1500 mL)

Ventilator Settings

Tidal Volume
• based on ideal body weight
• adjust to plateau pressure < 35 cm H₂O
  • • Non-pulmonary Problem
    5-8 mL/kg
    350–560 mL
  • • Lung Protective / ARDS
    3-6 mL/kg
    210–420 mL
  • • Obstructive
    6-8 mL/kg
    420–560 mL
Mode
  • • Volume Assist Control (AC)
  • • use cuffed ETT for volume-targeted ventilation
Rate
adjust based on SpO₂
  • • Traditional 10-12
  • • Lung Protective / ARDS 12-20
  • • Obstructive 5-8
  • • Hypovolemic 10-12
15-20 resp/min
PEEP
3-8 cm H₂O
  • • Recommended to start at 5
  • • Lung Protective / ARDS 2-15
  • • Obstructive 0.5
  • • Hypovolemic 0-5
3-5 cm H₂O
FiO₂
• initiate at 100% and wean down as tolerated
I:E Ratio
  • • Traditional 1:2
  • • Lung Protective / ARDS 1:2
  • • Obstructive 1:4 (permissive hypercapnia to avoid breath stacking)
  • • Hypovolemic 1:2
1:2 (1:3-5 if asthmatic)
Avoid Peak Pressures > 40
• Adjust to plateau pressure < 35 cm H₂O

Premedications

• Defasciculation unnecessary < 5 yo. • Atropine — some experts recommend < 5 yo, others recommend only if ≤ 1 yo.

Premedications

  • Atropine (Pre-RSI)

    Pretreatment infants <1 yr

    IV
    Dose
    0.500 mgMax
    Volume
    5.00 mL
    IV push• 0.1 mg/mL• 0.02 mg/kg

    Floor 0.1 mg per dose to prevent paradoxical bradycardia.

  • Lidocaine (Pre-RSI)

    Pretreatment (head injury)

    IV
    Dose
    100 mgMax
    Volume
    5.00 mL
    IV push 2-3 min before• 2% (20 mg/mL)• 1.5 mg/kg

  • Fentanyl

    Analgesia/sedation

    IV
    Dose
    0.070 mg
    Volume
    1.40 mL
    IV slow push• 50 mcg/mL• 0.001 mg/kg

    1 mcg/kg = 0.001 mg/kg

  • Vecuronium

    Paralytic - non-depolarizing

    IV
    Dose
    7.00 mg
    Volume
    7.00 mL
    IV push• 1 mg/mL (reconstitute w/ 10 mL sterile water)• 0.1 mg/kg

    Duration unpredictable / prolonged at this dose.

Induction Medications

• Consider decreasing the induction dose in hypotensive patients.

Induction

  • Etomidate

    Induction agent

    IV
    Dose
    21.0 mg
    Volume
    10.5 mL
    IV push• 2 mg/mL• 0.3 mg/kg

  • Ketamine (RSI)

    Induction agent (esp. shock/asthma)

    IV
    Dose
    140 mg
    Volume
    2.80 mL
    IV push• 50 mg/mL• 2 mg/kg

  • Propofol (RSI)

    Induction agent

    IV
    Dose
    140 mg
    Volume
    14.0 mL
    IV push• 10 mg/mL• 2 mg/kg

  • Midazolam (RSI)

    Induction agent

    IV
    Dose
    10.0 mgMax
    Volume
    2.00 mL
    IV push• 5 mg/mL• 0.2 mg/kg

Paralytics

  • Succinylcholine

    Paralytic - depolarizing

    IV
    Dose
    105 mg
    Volume
    5.25 mL
    IV push• 20 mg/mL• 1.5 mg/kg

    Use 2 mg/kg in infants < 1 yr. Avoid in hyperK+, burns >24h, neuromuscular dz.

  • Succinylcholine IM

    Paralytic IM (no IV access — pair with Ketamine IM)

    IM
    Dose
    200 mgMax
    Volume
    4.00 mL
    IM (deltoid/quadriceps)• 20 / 50 / 100 mg/mL• 4 mg/kg

    Use with Ketamine IM if no IV access. Avoid in renal failure, suspected hyperkalemia.

  • Rocuronium

    Paralytic - non-depolarizing

    IV
    Dose
    84.0 mg
    Volume
    8.40 mL
    IV push• 10 mg/mL• 1.2 mg/kg

    1-1.2 mg/kg IV (1.2 mg/kg preferred for RSI). Onset 1-3 min, lasts 30 min.

  • Vecuronium

    Paralytic - non-depolarizing

    IV
    Dose
    7.00 mg
    Volume
    7.00 mL
    IV push• 1 mg/mL (reconstitute w/ 10 mL sterile water)• 0.1 mg/kg

    Duration unpredictable / prolonged at this dose.

  • Pancuronium

    Paralytic - non-depolarizing (long-acting)

    IV
    Dose
    7.00 mg
    Volume
    3.50 mL
    IV push• 1 / 2 mg/mL• 0.1 mg/kg

    Avoid in asthmatics, renal failure.

  • Cisatracurium

    Paralytic - non-depolarizing

    IV
    Dose
    14.0 mg
    Volume
    7.00 mL
    IV push• 2 / 10 mg/mL• 0.2 mg/kg

    Onset 1-3 min, lasts 30-60 min. Hofmann elimination — safe in renal/hepatic dz.

  • Atracurium

    Paralytic - non-depolarizing

    IV
    Dose
    35.0 mg
    Volume
    3.50 mL
    IV push• 10 mg/mL• 0.5 mg/kg

    Use lower end of dosing if age < 2 years. Histamine release possible.

Reversal

  • Sugammadex

    Roc/Vec reversal

    IV
    Dose
    1120 mg
    Volume
    11.2 mL
    IV bolus• 100 mg/mL• 16 mg/kg

    16 mg/kg for immediate reversal; 4 mg/kg deep block; 2 mg/kg routine. Vecuronium reversal: 4 mg/kg.

Maintenance / Sedation

  • Fentanyl IV/IO Bolus

    Post-intubation analgesia bolus

    IV/IO
    Dose
    0.035 mg
    Volume
    0.700 mL
    IV/IO slow push• 50 mcg/mL• 0.0005 mg/kg

    0.5-1 mcg/kg per bolus.

  • Fentanyl Infusion

    Continuous sedation/analgesia

    IV
    Dose
    0.140 mg/hr
    Volume
    2.80 mL
    IV infusion• 50 mcg/mL• 0.002 mg/hr/kg

    2 mcg/kg/hr starting; concentrations vary by pharmacy — confirm before starting.

  • Hydromorphone IV/IO Bolus

    Post-intubation analgesia bolus (Dilaudid)

    IV/IO
    Dose
    0.350 mg
    Volume
    0.350 mL
    IV/IO slow push• 1 / 2 / 4 mg/mL• 0.005 mg/kg

    5-10 mcg/kg per bolus.

  • Hydromorphone Infusion

    Continuous opioid infusion (Dilaudid)

    IV
    Dose
    0.140 mg/hr
    Volume
    0.140 mL
    IV infusion• 1 / 2 / 4 mg/mL• 0.002 mg/hr/kg

    2 mcg/kg/hr starting. Concentrations vary by pharmacy — confirm before starting.

  • Propofol Infusion

    Continuous sedation

    IV
    Dose
    0.700 mg/min
    Volume
    0.070 mL
    IV infusion• 10 mg/mL• 0.01 mg/min/kg

    10-100 mcg/kg/min. Watch for PRIS in prolonged peds use.

  • Lorazepam IV/IO Bolus

    Post-intubation sedation (Ativan)

    IV/IO
    Dose
    2.00 mgMax
    Volume
    1.00 mL
    IV/IO push• 2 mg/mL• 0.05 mg/kg

  • Lorazepam Infusion

    Continuous benzodiazepine sedation (Ativan)

    IV
    Dose
    3.50 mg/hr
    Volume
    1.75 mL
    IV infusion• 2 mg/mL• 0.05 mg/hr/kg

    Avoid prolonged use — propylene glycol toxicity risk.

  • Midazolam Infusion

    Continuous benzodiazepine sedation (Versed)

    IV
    Dose
    2.00 mg/hrMax
    Volume
    2.00 mL
    IV infusion• 1 / 5 mg/mL• 0.05 mg/hr/kg

    < 50 kg: 0.05 mg/kg/hr. > 50 kg: ~2 mg/hr fixed start. Titrate to RASS.

  • Ketamine Infusion

    Continuous sedation / analgesia (Ketalar)

    IV
    Dose
    35.0 mg/kg/hr
    Volume
    3.50 mL
    IV infusion• 10 / 50 mg/mL• 0.5 mg/kg/hr/kg

    Range 0.5-2 mg/kg/hr. Bronchodilator, preserves hemodynamics.

  • Dexmedetomidine IV/IO Bolus

    Sedation loading dose (Precedex)

    IV
    Dose
    0.035 mg
    Volume
    8.75 mL
    IV over 10 min• 4 mcg/mL (diluted)• 0.0005 mg/kg

    0.5-1 mcg/kg over 10 min. 200 mcg/2 mL vial requires dilution. Watch for bradycardia/hypotension.

  • Dexmedetomidine Infusion

    Continuous sedation (Precedex)

    IV
    Dose
    0.003 mg/kg/hrMax
    Volume
    0.625 mL
    IV infusion• 4 mcg/mL standard• 0.0002 mg/kg/hr/kg

    0.2-2.5 mcg/kg/hr. Minimal respiratory depression; may cause bradycardia.

Continuous Paralytic Infusions

  • Vecuronium Infusion

    Continuous paralysis (Norcuron)

    IV
    Dose
    3.50 mg/kg/hr
    Volume
    3.50 mL
    IV infusion• 1 mg/mL• 0.05 mg/kg/hr/kg

    0.05-0.15 mg/kg/hr OR 0.8-2.5 mcg/kg/min. Train-of-four monitoring required.

  • Rocuronium Infusion

    Continuous paralysis (Zemuron)

    IV
    Dose
    21.0 mg/kg/hr
    Volume
    2.10 mL
    IV infusion• 10 mg/mL• 0.3 mg/kg/hr/kg

    0.3-1 mg/kg/hr. Adequate sedation MUST precede paralysis.

  • Cisatracurium Infusion

    Continuous paralysis (Nimbex)

    IV
    Dose
    7.00 mg/kg/hr
    Volume
    3.50 mL
    IV infusion• 2 / 10 mg/mL• 0.1 mg/kg/hr/kg

    0.1-1 mg/kg/hr. Hofmann elimination — preferred in renal/hepatic dysfunction.