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intubating an awake but paralyzed patient. Propofol is nice in the setting of status epilepticus, because it tends to break seizures better than other induction agents. Again, because of the short duration of action, you may need to give more. It also tends to drop patients' BP more than the other agents and suppresses respiratory drive at least as much as the benzo/opiate combo. I tend to avoid it in pretty much any intubating situation other than status epilepticus, especially in hypotensive patients. Ketamine, like etomidate, leaves respira- tory drive mostly intact. It has some useful side effects, including pain control, broncho- dilation—nice for your respiratory patients— and a weak pressor effect, which is nice for your hypotensive patients. It has the benefit of being relatively long-acting, so there's less redosing. I'm a huge fan of ketamine. You'll need to pair your sedative with a paralytic. Succinylcholine has always been popular because of its short duration of action (less than 4–6 mins.), as long as you avoid using it anytime you suspect hyperka- lemia. Rocuronium doesn't have that contra- indication but lasts longer (30–40 mins.), so be sure to use a longer-acting sedative (yay for ketamine!) or rebolus a short-acting one. Other medications that were traditionally used haven't been shown to be as useful as once thought. Lidocaine was supposed to blunt sympathetic stimulation and ICP rise, but the effect isn't reliable and has never been shown to be clinically meaningful. The same goes for "defasciculating" doses of paralytics. Gene: So here's how it goes (vary as indi- cated depending on the capabilities of your crew members): Clear the airway and keep it clear as your partner gets a line. While that is going on, mentally figure your patient's weight and the dose of sedation you're going to use. You should know the doses by memory. As soon as the line is in, have your partner take over airway management and draw up and push your sedative. As the sedative takes effect, your part- ner preoxygenates your patient to 98%. Preoxygenation techniques include a non- rebreather mask at 15 lpm if your patient is breathing on his own, together with a nasal cannula hooked to a separate oxygen regulator running at 15 lpm also. This will optimally preoxygenate your patient. If, after 3–5 minutes of this, your patient still does not have an oxygen saturation better than 90%, there is a shunt in place. It will be necessary to use CPAP or BiPAP or BVM ventilation to overcome this. Check out your laryngoscope and tubes, leaving the syringes attached to the cuff inflators. Draw up your paralytic, long-term sedative and long-term paralytic. Check your patient's oxygen saturation. If he is at 98% or above, push your paralytic, wait for paralysis and intubate. Take your time. You have far more than 30 seconds to intu- bate. If you encounter problems, see what EMSWORLD.com | OCTOBER 2015 53 *For terms and conditions please visit www.buyemp.com/customer-service.html BuyEMP.com You order. We ship (free). * It's that simple. EMPower your savings by joining our Online Loyalty Rewards Program. Join now and receive 250 loyalty points! • Earn points, redeem for $ savings on future orders • Exclusive promotional offers to double & triple your points • First alerts on new product additions to our program • Savings on everyday run items, more additions coming soon! Visit www.BuyEMP.com today to get started! EMPOWER Join Earn Redeem It's that simple For More Information Circle 32 on Reader Service Card