Severe Trauma Airway Management & Emergency RSI Protocol

Emergency Rapid Sequence Intubation (RSI) in trauma patients is fraught with physiological landmines. Unlike elective anaesthesia, emergency intubation carries a 30-40% incidence of peri-intubation hypotension or severe desaturation.

1. Physiological Pre-Oxygenation & Optimization

Prior to laryngoscopy, oxygenation must be maximized while preserving hemodynamic stability.

Emergency Airway & RSI Protocol Flowchart — Figure 1: Resus Docs Emergency Airway & RSI Algorithm with FONA rescue branch.

2. Induction & Paralytic Dosing Matrix

In trauma resuscitation, dosing must be weight-adjusted to hemodynamic status. In shocked patients, cut the induction agent dose by 50% while maintaining or increasing the paralytic dose.

Agent	Standard Dose	Shocked / Trauma Dose	Onset	Duration	Clinical Pearls
Ketamine	1.5 - 2.0 mg/kg	0.5 - 1.0 mg/kg	45 sec	10-20 min	Hemodynamically neutral, bronchodilator
Etomidate	0.3 mg/kg	0.15 mg/kg	30 sec	5-15 min	Adrenal suppression caveat
Rocuronium	1.2 mg/kg	1.5 mg/kg	45 sec	45-60 min	High dose ensures rapid onset in low cardiac output
Succinylcholine	1.5 mg/kg	1.5 mg/kg	30 sec	6-10 min	Avoid in hyperkalemia, burns >24h, crush syndrome

Pre-oxygenation setup — Side Note: Keep Scalpel-Bougie-Tube FONA kit open and visible at bedside before first attempt.

3. Video Laryngoscopy & Difficult Airway Rescue

Hyperangulated video laryngoscopy improves first-pass success rate to over 92% in trauma airways.

# Emergency RSI Preparation Checklist
[x] Pre-ox 3 min (SpO2 > 95% target)
[x] Push-dose Noradrenaline (10 mcg/mL) drawn up
[x] Video Laryngoscope tested & operational
[x] Bougie / Stylet pre-loaded in ETT 7.5
[x] Continuous Waveform Capnography connected
[x] Scalpel 10 blade + Bougie + Cuffed ETT 6.0 (FONA Kit)

Confirmation & Post-Intubation Care

Verify continuous 6-wave ETCO2 capnography waveform.
Target SBP > 100 mmHg and MAP > 65 mmHg (or MAP > 85 mmHg in Traumatic Brain Injury).
Obtain immediate post-intubation chest X-ray to confirm tube tip 3-5 cm above carina.