7.1 Pharmacologic Assisted Intubation

Pharmacologic assisted intubation (PAI) is a drug sequence, not a blade trick. Domain 2 of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests induction choice, paralytic choice, and the decision to delay or skip a drug when physiology says so. Rapid sequence intubation (RSI) is the usual method: almost-simultaneous induction and neuromuscular blockade so a full-stomach patient does not vomit into an open glottis. The milligram numbers below are typical adult critical-care starting doses used as clinical teaching. BCEN does not publish a dose table.

RSI, PAI, and the death of pretreatment

RSI is the sequence you run: preoxygenate, induce, paralyze, look. A full stomach still gets RSI if the patient needs a tube.

Pretreatment is rarely used now

Classic checklists stacked lidocaine, a defasciculating dose of rocuronium, fentanyl, and atropine before induction. Those pretreatment drugs add time and rarely change flight outcomes. Lidocaine does not reliably blunt intracranial pressure. A small rocuronium primer can leave a weak, still-vomiting patient. Atropine is not routine in adults. If you give fentanyl on the ramp, give it as analgesia, not as a mandatory pretreatment box.

Induction agents

Choose the drug for the circulation in front of you, then cut the dose if shock is still present.

Etomidate

Etomidate 0.3 mg/kg intravenous (IV) is hemodynamically quiet in most adults. Profound shock still loses sympathetic tone, so many programs teach 0.15–0.2 mg/kg as a shock dose. Transient adrenal suppression matters more for later intensive care than for a two-minute scene tube. Myoclonus can look like seizure—warn the partner.

Ketamine

Ketamine 1–2 mg/kg IV usually supports blood pressure through catecholamine release and leaves some respiratory drive. In catecholamine-depleted shock it can still vasodilate, so teach 0.5–1 mg/kg as a shock dose. It is the induction of choice for delayed sequence intubation (DSI), bronchospasm, and many hypotensive trauma patients. A large bolus in an empty catecholamine tank will still drop mean arterial pressure (MAP).

Propofol cautions

Propofol 1–2 mg/kg IV is a vasodilator and a negative inotrope. Even 0.5 mg/kg can empty a hemorrhaging patient, a tamponade, or a failing right ventricle. Save it for the volume-replete airway, or use it later as an infusion once pressure is real. Midazolam 0.1–0.3 mg/kg is slow and hypotensive; it is a poor sole induction agent when the rotor is turning.

Paralytics

Succinylcholine versus rocuronium

Succinylcholine 1–1.5 mg/kg IV is a depolarizing blocker with roughly a 30–60 second onset and a 6–10 minute duration. It is contraindicated when extra-junctional acetylcholine receptors will dump potassium: known or suspected hyperkalemia, burns after 24 hours, crush or denervation after a similar delay, many neuromuscular diseases, and any personal or family malignant hyperthermia (MH) risk.

Rocuronium 1–1.2 mg/kg IV is the nondepolarizing RSI dose. Onset is about 45–90 seconds; paralysis lasts 45–70 minutes. It does not trigger hyperkalemia or MH. The price is a long, still, unsated patient if you forget post-intubation drugs (section 7.2). Sugammadex can reverse rocuronium in a hospital; do not plan a flight around a reversal drug you may not carry.

When to skip paralysis

Skip the paralytic when a surgical airway is already the indicated first airway—laryngeal fracture, massive facial disruption, or anatomy you cannot intubate or oxygenate from above. Paralyzing a patient you cannot bag and cannot tube is how you own the arrest. An awake look or a primary cricothyrotomy is the plan. Do not paralyze just to quiet the video screen if the failed-airway plan is already a knife.

DSI, no-desat, shock doses, and the cabin

DSI uses dissociative ketamine so an agitated, hypoxic patient will accept a mask. After the saturation rises, you give the paralytic and look. DSI is a preoxygenation strategy, not a different laryngoscopy. No-desat means a flush-rate nasal cannula (NC) stays on through the attempt. You can combine DSI with no-desat. Neither replaces blood or a vasopressor.

Shock-dose reductions apply to induction, not to RSI rocuronium. Cutting rocuronium to 0.6 mg/kg just delays paralysis. Cut etomidate, ketamine, or propofol. Raise MAP first (Chapter 6).

Draw the drugs before launch when you know the patient will need a tube. Estimate weight on the ramp. Label every syringe. In a vibrating cabin, 10 mg/mL ketamine looks like 50 mg/mL ketamine, and a 10 mL rocuronium syringe looks like a flush. Double-check the concentration against the vial. Verbalize the plan: ketamine one hundred, roc one hundred, if I fail we bag, then i-gel, then cric. Touch the cricothyrotomy kit. Leave the NC running. If the aircraft is still on the ramp, induce there.

• Draw, label, and cross-check concentrations before the rotor turns.
• Use shock-dose induction; do not cut the RSI rocuronium dose.
• Hold succinylcholine after 24-hour burns, crush, hyperkalemia, neuromuscular disease, or MH risk.
• Use DSI plus no-desat when agitation is blocking preoxygenation.
• Skip paralysis when the first airway is already surgical.

Practice these stems in the CFRN practice bank. Critical-care induction habits from the CCRN study guide still apply—then add a vibrating cabin and a labeled syringe you can actually read.