A standardized rapid sequence intubation protocol facilitates airway management in critically injured patients

J Trauma Acute Care Surg. 2012 Dec;73(6):1401-5. doi: 10.1097/TA.0b013e318270dcf5.


Background: In the emergency department (ED) of a teaching hospital, rapid sequence intubation (RSI) is performed by physicians with a wide range of experience. A variety of medications have been used for RSI, with potential for inadequate or excessive dosing as well as complications including hypotension and the need for redosing. We hypothesized that the use of a standardized RSI medication protocol has facilitated endotracheal intubation requiring less medication redosing and less medication-related hypotension.

Methods: An RSI medication protocol (ketamine 2 mg/kg intravenously administered and rocuronium 1 mg/kg intravenously administered, or succinylcholine 1.5 mg/kg intravenously administered) was implemented for all trauma patients undergoing ED intubation at a Level I trauma center. We retrospectively reviewed patients for the 1-year period before (PRE) and after (KET) the protocol was instituted. Data collected included age, sex, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) score of the head/face, AIS score of the chest, RSI drugs, need for redosing, time to intubation, indication for RSI, and number of RSI attempts.

Results: During the study period, 439 patients met inclusion criteria; 266 without protocol (PRE) and 173 with protocol (KET). Patients were severely injured with a mean ISS of 24 and median AIS score of the head/face of 3. Dosing in the KET group was appropriate with a mean dose of 1.9-mg/kg ketamine administered. Compliance after KET introduction approached 90%. Fifteen patients in the PRE group required redosing of medication versus three in the KET group (p < 0.05, χ). For patients younger than 14 years, (26 in PRE and 10 in KET), 2 patients in the PRE group required redosing and none in the KET group (not significant). In all patients, mean time from drug administration to intubation decreased from 4 minutes to 3 minutes.

Conclusion: A standardized medication protocol simplifies RSI and allows efficient airway management of critically injured trauma patients in the ED of a teaching hospital. Incorporation of ketamine avoids potential complications of other commonly used RSI medications.

Level of evidence: Therapeutic study, level IV.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Airway Management / methods*
  • Airway Management / standards
  • Androstanols / administration & dosage
  • Anesthesia / methods*
  • Anesthesia / standards
  • Anesthetics, Dissociative / administration & dosage
  • Child
  • Child, Preschool
  • Clinical Protocols*
  • Female
  • Humans
  • Infant
  • Injury Severity Score
  • Intubation, Intratracheal / methods*
  • Intubation, Intratracheal / standards
  • Ketamine / administration & dosage
  • Male
  • Middle Aged
  • Neuromuscular Nondepolarizing Agents / administration & dosage
  • Rocuronium
  • Succinylcholine / administration & dosage
  • Time Factors
  • Treatment Outcome
  • Wounds and Injuries / therapy*
  • Young Adult


  • Androstanols
  • Anesthetics, Dissociative
  • Neuromuscular Nondepolarizing Agents
  • Ketamine
  • Succinylcholine
  • Rocuronium