SOAPME: (Suction, oxygen, airway, pharmacology, monitoring, equipment)
Nitrogen wash-out
100% NRB for 3-5min or 8 VC breaths (BVM) with high-flow O2
Apneic oxygenation with NC at 6L/min while setting up and increase to 15L/min once patient is sedated
100% NRB for 3-5min or 8 VC breaths (BVM) with high-flow O2
Apneic oxygenation with NC at 6L/min while setting up and increase to 15L/min once patient is sedated
Ischemic heart disease/dissection: Fentanyl 3-5mcg/kg
Increased ICP: Fentanyl 3-5mcg/kg (+/- lidocaine 1.5mg/kg (some think drop in MAP not worth it))
Reactive Airway disease: Lidocaine 1.5mg/kg (suppresses cough reflex)
Peds (age <1): Atropine 0.01-.02mg/kg (min 0.1mg, max 0.5mg)
Controversial
Controversial
INDUCTION
Etomidate (0.3mg/kg)
Especially good for hypotensive/trauma patients
Hemodynamically neutral, lowers ICP
Lowers seizure threshold in patients with known seizure disorder
Does NOT blunt sympathetic reaction to<unk>  (no analgesic effect)
Adrenal suppression is likely irrelevant with one-time dose
Ketamine (1-4mg/kg)
Agent of choice for asthmatics as it has bronchodilator effects. Also consider with hypotension (i.e.: septic shock)
Available in IM form
Sympathomimetic
Avoid in patient with significant HTN
Evidence for clinically significant rise in ICP equivocal at best. Consider use in head injured patients with increased ICP AND low or normal BP
Midazolam (0.2mg/kg)
Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure)
Consider in patient in status epilepticus (anti-seizure effect)
May decrease MAP, especially if patient hypovolemic
Propofol (1.5 to 3mg/kg)
Consider in patient with bronchospasm
Decreases MAP, CPP
PARALYSIS
Succinylcholine
1.5mg/kg - better to overdose than to underdose
2mg/kg - neonates/infants
Contraindications
Stroke <6 months old, MS, muscular dystrophies
ECG changes consistent with hyperkalemia
OK to use in crush injury, acute stroke as long as within 3 days of occurrence
Rocuronium
1-1.2mg/kg
Consider not paralyzing in these situations
Expanding neck hematoma, to keep integrity of strap muscles
Unable to BVM due to facial hair, micrognathia
Unable to move to cricothyroidotomy (angioedema, goiter, anterior neck mass)
Etomidate (0.3mg/kg)
Especially good for hypotensive/trauma patients
Hemodynamically neutral, lowers ICP
Lowers seizure threshold in patients with known seizure disorder
Does NOT blunt sympathetic reaction to<unk>  (no analgesic effect)
Adrenal suppression is likely irrelevant with one-time dose
Ketamine (1-4mg/kg)
Agent of choice for asthmatics as it has bronchodilator effects. Also consider with hypotension (i.e.: septic shock)
Available in IM form
Sympathomimetic
Avoid in patient with significant HTN
Evidence for clinically significant rise in ICP equivocal at best. Consider use in head injured patients with increased ICP AND low or normal BP
Midazolam (0.2mg/kg)
Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure)
Consider in patient in status epilepticus (anti-seizure effect)
May decrease MAP, especially if patient hypovolemic
Propofol (1.5 to 3mg/kg)
Consider in patient with bronchospasm
Decreases MAP, CPP
Especially good for hypotensive/trauma patients
Hemodynamically neutral, lowers ICP
Lowers seizure threshold in patients with known seizure disorder
Does NOT blunt sympathetic reaction to<unk>  (no analgesic effect)
Adrenal suppression is likely irrelevant with one-time dose
Agent of choice for asthmatics as it has bronchodilator effects. Also consider with hypotension (i.e.: septic shock)
Available in IM form
Sympathomimetic
Avoid in patient with significant HTN
Evidence for clinically significant rise in ICP equivocal at best. Consider use in head injured patients with increased ICP AND low or normal BP
Avoid in patient with significant HTN
Evidence for clinically significant rise in ICP equivocal at best. Consider use in head injured patients with increased ICP AND low or normal BP
Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure)
Consider in patient in status epilepticus (anti-seizure effect)
May decrease MAP, especially if patient hypovolemic
Consider in patient with bronchospasm
Decreases MAP, CPP
Succinylcholine
1.5mg/kg - better to overdose than to underdose
2mg/kg - neonates/infants
Contraindications
Stroke <6 months old, MS, muscular dystrophies
ECG changes consistent with hyperkalemia
OK to use in crush injury, acute stroke as long as within 3 days of occurrence
Rocuronium
1-1.2mg/kg
Consider not paralyzing in these situations
Expanding neck hematoma, to keep integrity of strap muscles
Unable to BVM due to facial hair, micrognathia
Unable to move to cricothyroidotomy (angioedema, goiter, anterior neck mass)
1.5mg/kg - better to overdose than to underdose
2mg/kg - neonates/infants
Stroke <6 months old, MS, muscular dystrophies
ECG changes consistent with hyperkalemia
OK to use in crush injury, acute stroke as long as within 3 days of occurrence
1-1.2mg/kg
Expanding neck hematoma, to keep integrity of strap muscles
Unable to BVM due to facial hair, micrognathia
Unable to move to cricothyroidotomy (angioedema, goiter, anterior neck mass)
Sniffing position
in cervical spine immobilization, use bimanual laryngoscopy and consider adjuncts such as bougie or video laryngoscopy if minimal blood in oropharynx<unk> 
End-tidal CO2 detection is primary means of ETT placement confirmation
Cola-complication: need CO2 detection for at least 6 ventilations
CXR
Non-violent restraints
Head of bed to 30° elevation
Check ABG 30 minutes post-intubation
Sedation
Benzos
Lorazepam 1-4mg bolus; then 0.01-0.1mg/kg/hr (titrate q1hr)
Midazolam 1-5mg bolus; then 0.04-0.2mg/kg/hr (titrate q1hr)
Propofol
5-80mcg/kg/min (titrate q10min)
Analgesia
Fentanyl 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min)
Paralysis (if needed)
Vecuronium 10mg, then 7mg/hr
Benzos
Lorazepam 1-4mg bolus; then 0.01-0.1mg/kg/hr (titrate q1hr)
Midazolam 1-5mg bolus; then 0.04-0.2mg/kg/hr (titrate q1hr)
Propofol
5-80mcg/kg/min (titrate q10min)
Lorazepam 1-4mg bolus; then 0.01-0.1mg/kg/hr (titrate q1hr)
Midazolam 1-5mg bolus; then 0.04-0.2mg/kg/hr (titrate q1hr)
5-80mcg/kg/min (titrate q10min)
Fentanyl 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min)
Vecuronium 10mg, then 7mg/hr
Rapid sequence intubation
Delayed sequence intubation
Awake intubation
Extubation
Intubation
Intubation 
Extracorporeal membrane oxygenation
Needle cricothyrotomy