Can you provide a sample set of emergency department physician orders for an adult patient with respiratory failure requiring rapid sequence intubation?

Sample Emergency Department Orders for Rapid Sequence Intubation in Adult Respiratory Failure

For an adult patient requiring RSI in the ED, administer a sedative-hypnotic induction agent combined with a neuromuscular blocking agent (NMBA), with etomidate or ketamine as first-line induction agents and either succinylcholine or rocuronium for paralysis 1.

Pre-Intubation Orders

Preoxygenation

• Apply high-flow nasal cannula (HFNC) or noninvasive positive pressure ventilation (NIV) for preoxygenation 2, 3
• Target: SpO2 >95% for 3-5 minutes prior to induction
• Continue apneic oxygenation with HFNC during intubation attempt

Monitoring

• Continuous cardiac monitoring, pulse oximetry, capnography
• Blood pressure monitoring (automated q1 minute during procedure)
• IV access x2 (minimum 18-gauge)

Equipment Preparation

• Video laryngoscopy as primary device (preferred over direct laryngoscopy for higher first-pass success) 4, 3
• Bougie available at bedside
• Endotracheal tubes: 7.0,7.5,8.0 mm (have multiple sizes ready)
• Backup airway equipment: supraglottic airway device, cricothyrotomy kit

Medication Orders for RSI

Induction Agent (Choose One Based on Hemodynamics)

For hemodynamically stable or mildly unstable patients:

• Etomidate 0.3 mg/kg IV push (0.2-0.3 mg/kg range acceptable) 1
  • Dose reduction to 0.15 mg/kg if severe hemodynamic compromise
  • Most commonly used in community EDs (91.6% of cases) 4

For hemodynamically unstable patients with shock:

• Etomidate 0.2-0.3 mg/kg IV push (retrospective evidence suggests less hypotension than ketamine in shock/sepsis) 5
• Alternative: Ketamine 1-2 mg/kg IV push 1
  • Note: Ketamine has sympathomimetic properties but may cause hypotension in catecholamine-depleted states

The 2023 SCCM guidelines indicate no mortality difference between etomidate and other induction agents 1, so selection should be based on hemodynamic profile rather than mortality concerns.

Neuromuscular Blocking Agent (Choose One)

Option 1: Succinylcholine 1.5 mg/kg IV push 1

• Fastest onset (45-60 seconds)
• Shortest duration (5-10 minutes)
• Contraindications: hyperkalemia risk, malignant hyperthermia history, chronic denervation

Option 2: Rocuronium 1.0-1.2 mg/kg IV push 5, 4

• Onset 60-90 seconds at high dose
• Longer duration (45-60 minutes)
• Trend shows increasing use: 33.9% in 2015 to 61.9% in 2022 4
• Reversible with sugammadex if needed

Administration Sequence

Administer the NMBA first, followed immediately by the sedative-hypnotic agent (may reduce apnea time by 6 seconds, though either order is acceptable) 6. The critical point is that both agents must be given when using an NMBA to prevent awareness with paralysis 1.

Post-Intubation Orders

Immediate Confirmation

• Continuous waveform capnography (mandatory) 3
• Alternative/adjunct: Point-of-care ultrasound visualization of lung sliding
• Chest X-ray (portable, stat)

Post-Intubation Sedation and Analgesia

• Fentanyl 50-100 mcg IV q5-10 minutes PRN (for analgesia)
• Propofol infusion 20-50 mcg/kg/min OR Midazolam 1-2 mg IV q15 minutes PRN (for sedation)
• Critical: Ensure adequate sedation to prevent awareness with paralysis 3

Ventilator Settings (Initial)

• Mode: Volume control or pressure control
• Tidal volume: 6-8 mL/kg ideal body weight (lung-protective strategy)
• Respiratory rate: 12-16 breaths/minute (adjust for pH/PaCO2)
• FiO2: 100% initially, then titrate to SpO2 88-95%
• PEEP: 5-8 cm H2O initially (titrate based on oxygenation and ARDS severity) 7

Hemodynamic Support (If Needed)

• Prepare vasopressor infusion BEFORE induction if patient is in shock
• Norepinephrine 0.05-0.5 mcg/kg/min (first-line)
• Push-dose pressors available: phenylephrine 100-200 mcg IV push PRN
• IV fluid bolus: 500 mL crystalloid (if volume responsive)

Common Pitfalls to Avoid

• Never administer NMBA alone without sedative-hypnotic agent 1 - this causes awareness with paralysis
• Avoid propofol as induction agent in hemodynamically unstable patients - it has the most profound hypotensive effect 1
• Do not skip preoxygenation - peri-intubation hypoxemia is a major cause of complications
• Avoid midazolam for RSI induction - slower onset and potent venodilation at RSI doses 1
• Pretreatment agents (atropine, lidocaine, fentanyl) are no longer routinely recommended - limited evidence outside select scenarios 5

Risk Stratification Note

First-pass success rate in community EDs is 80.5% with failure rate of 0.2% 4, but intubated patients have high mortality: 19.7% at 24 hours, 38.4% at 30 days 4. This reflects the severity of illness rather than procedural complications, but emphasizes the need for meticulous technique and post-intubation care.