Quick Reference Cards
Rapid Sequence Induction (RSI)Critical
airway
Steps
1
Preoxygenation
3-5 min 100% O₂ via tight-fitting mask or 8 vital capacity breaths with high-flow O₂
3-5 min
2
Pretreatment (optional)
3 min before induction
- Fentanyl 1-3 mcg/kg IV (blunts sympathetic response)
- Lidocaine 1.5 mg/kg IV (reduces ICP, airway reactivity)
3
Induction agent
- Propofol 1.5-2.5 mg/kg IV
- Etomidate 0.3 mg/kg IV (hemodynamically stable)
- Ketamine 1-2 mg/kg IV (preserves hemodynamics)
4
Paralytic (immediately after induction)
- Succinylcholine 1.5 mg/kg IV (onset 45-60 sec)
- Rocuronium 1.2 mg/kg IV (onset 60 sec)
5
Cricoid pressure (Sellick maneuver)
Apply 30 N of force to cricoid cartilage. Release if impedes intubation or causes vomiting.
6
Intubation
Attempt laryngoscopy at 45-60 sec after paralytic. Avoid ventilation unless SpO₂ < 93%.
45-60 sec
7
Confirm placement
- ETCO₂ waveform (gold standard)
- Bilateral breath sounds auscultation
- Chest rise symmetry
- SpO₂ monitoring
8
Failed airway pathway
Can intubate?
YESConfirm ETT placement, secure tube
NOReposition, bougie, video laryngoscope → SGA → Surgical airway
Medications
| Drug | Dose | Route | Timing |
|---|---|---|---|
| Propofol | 1.5-2.5 mg/kg | IV | Induction |
| Etomidate | 0.3 mg/kg | IV | Induction |
| Ketamine | 1-2 mg/kg | IV | Induction |
| Succinylcholine | 1.5 mg/kg | IV | Paralytic |
| Rocuronium | 1.2 mg/kg | IV | Paralytic |
| Fentanyl | 1-3 mcg/kg | IV | Pretreatment |
| Lidocaine | 1.5 mg/kg | IV | Pretreatment |
Equipment Checklist
- 2 laryngoscope handles (tested)
- ETT (primary size + 0.5 above and below)
- Bougie / stylet
- Suction (Yankauer)
- Backup supraglottic airway (LMA)
- Cricothyrotomy kit
- ETCO₂ detector
- BVM with PEEP valve
- Video laryngoscope
Key Points
- No bag-mask ventilation between induction and intubation (aspiration risk)
- Succinylcholine contraindicated: burns >24h, crush injury, denervation, hyperkalemia, myopathies, MH susceptibility
- Rocuronium can be reversed with sugammadex 16 mg/kg
- Have backup airway plan before starting RSI
- If SpO₂ drops below 93%, gentle ventilation with cricoid pressure is acceptable
Difficult Airway Algorithm (ASA 2022)Critical
airway
Steps
1
Airway assessment
- LEMON: Look externally, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility
- Mallampati class (I-IV)
- Thyromental distance (<6 cm = concerning)
- Mouth opening (<3 cm = limited)
- Neck mobility / C-spine restrictions
- History of prior difficult intubation
2
Anticipated difficult airway
Is the airway anticipated to be difficult?
YESProceed to awake intubation pathway (Step 3)
NOProceed with standard induction (Step 4)
3
Awake intubation pathway
Patient maintains spontaneous ventilation throughout
- Topicalize airway (lidocaine 4% nebulized or atomized)
- Sedation: Dexmedetomidine or Remifentanil infusion
- Flexible bronchoscopic intubation (preferred)
- Video laryngoscopy while awake
- Retrograde wire technique (rare)
4
Unanticipated difficult — Attempt #1 failed
- Optimize: Reposition head/neck (ear-to-sternal notch)
- BURP maneuver (Backward, Upward, Rightward Pressure)
- Use bougie as first adjunct
- Switch to video laryngoscope
5
Attempt #2 failed — Supraglottic airway
Limit total intubation attempts to 3 (+1 by expert)
- Insert supraglottic airway (LMA, i-gel)
- Confirm ventilation via ETCO₂
- Consider intubation through SGA if needed
6
SGA failed — CICO emergency
Can't Intubate, Can't Oxygenate — declare emergency, call for help
Can oxygenate via SGA or BVM?
YESMaintain oxygenation, wake patient if possible
NOEmergency front-of-neck access (FONA) immediately
7
Emergency front-of-neck access (FONA)
Needle cricothyrotomy only as temporizing measure in adults
- Scalpel cricothyrotomy (preferred in adults)
- Palpate cricothyroid membrane
- Horizontal stab incision through membrane
- Bougie through incision, railroad ETT (6.0)
- Confirm ETCO₂
Medications
| Drug | Dose | Route | Timing |
|---|---|---|---|
| Lidocaine 4% | 4-5 mL | Nebulized/Atomized | Topicalization |
| Glycopyrrolate | 0.2 mg | IV | Antisialagogue |
| Dexmedetomidine | 1 mcg/kg over 10 min | IV | Awake sedation |
| Remifentanil | 0.05-0.1 mcg/kg/min | IV infusion | Awake sedation |
Equipment Checklist
- Video laryngoscope (hyperangulated + standard blades)
- Flexible bronchoscope
- Supraglottic airways (multiple sizes)
- Bougie and stylets
- Cricothyrotomy kit (scalpel, bougie, 6.0 ETT)
- Topicalization supplies (lidocaine 4%, atomizer)
- Capnography
Key Points
- Always have a primary plan and at least one backup plan
- Limit direct laryngoscopy attempts to prevent airway trauma/edema
- Call for help early — do not wait until CICO
- Video laryngoscopy should be considered on first attempt for predicted difficulty
- Maintain oxygenation as the primary goal throughout
- CICO is rare (<0.5%) but requires immediate surgical airway
ACLS Cardiac Arrest (VF/pVT vs PEA/Asystole)Critical
cardiac
Steps
1
Start high-quality CPR
- Rate 100-120 compressions/min
- Depth ≥2 inches (5 cm)
- Full chest recoil between compressions
- Minimize interruptions (<10 sec)
2
Attach defibrillator — analyze rhythm
Is rhythm shockable (VF/pVT)?
YESDefibrillate 120-200J biphasic → Resume CPR 2 min → Step 3
NOPEA/Asystole → CPR 2 min + Epinephrine ASAP → Step 4
3
Shockable rhythm pathway (VF/pVT)
- Shock → CPR 2 min → Recheck rhythm
- Epinephrine 1 mg IV q3-5 min (after 2nd shock)
- Amiodarone 300 mg IV (after 3rd shock)
- Amiodarone 150 mg IV (may repeat once)
- Continue CPR-shock-drug cycles
4
Non-shockable pathway (PEA/Asystole)
- CPR 2 min → Recheck rhythm
- Epinephrine 1 mg IV q3-5 min (give immediately)
- Search for and treat reversible causes (H’s and T’s)
- If rhythm changes to shockable → go to Step 3
5
Reversible causes (H’s and T’s)
- Hypovolemia — volume resuscitation
- Hypoxia — oxygenate, confirm ETT
- Hydrogen ion (acidosis) — NaHCO₃
- Hypo/Hyperkalemia — treat electrolytes
- Hypothermia — active rewarming
- Tension pneumothorax — needle decompression
- Tamponade — pericardiocentesis
- Toxins — specific antidotes
- Thrombosis (coronary) — PCI
- Thrombosis (pulmonary) — fibrinolytics
Medications
| Drug | Dose | Route | Timing |
|---|---|---|---|
| Epinephrine | 1 mg | IV/IO | q3-5 min |
| Amiodarone | 300 mg | IV/IO | 1st dose after 3rd shock |
| Amiodarone | 150 mg | IV/IO | 2nd dose (may repeat once) |
| Lidocaine | 1-1.5 mg/kg | IV/IO | Alternative to amiodarone |
| Sodium bicarbonate | 1 mEq/kg | IV | If known acidosis/hyperK |
Key Points
- High-quality CPR is the single most important intervention
- Epinephrine: 1 mg IV/IO q3-5 min throughout arrest
- Amiodarone only for refractory VF/pVT
- Minimize pauses in compressions for rhythm checks (<10 sec)
- Consider advanced airways but do not interrupt CPR
- ROSC: Start post-cardiac arrest care, targeted temp management
ACLS Bradycardia with PulseUrgent
cardiac
Steps
1
Identify symptomatic bradycardia
- HR typically < 50 bpm with symptoms
- Hypotension, altered mental status, signs of shock
- Ischemic chest discomfort
- Acute heart failure
2
Maintain airway, breathing, IV access
12-lead ECG, monitor, pulse oximetry. Identify and treat underlying cause.
3
Atropine first-line
1 mg IV q3-5 min, max total dose 3 mg. May not be effective for Mobitz II or 3rd degree block.
4
If atropine ineffective
Is the patient hemodynamically stable after atropine?
YESMonitor, consider cardiology consult for pacing
NOTranscutaneous pacing OR vasopressor infusion (Step 5)
5
Transcutaneous pacing or vasopressors
- TCP: Start at 60 bpm, increase mA until capture
- Dopamine 5-20 mcg/kg/min IV infusion
- Epinephrine 2-10 mcg/min IV infusion
- Consider transvenous pacing for refractory cases
Medications
| Drug | Dose | Route | Timing |
|---|---|---|---|
| Atropine | 1 mg | IV | q3-5 min, max 3 mg |
| Dopamine | 5-20 mcg/kg/min | IV infusion | If atropine fails |
| Epinephrine | 2-10 mcg/min | IV infusion | If atropine fails |
| Isoproterenol | 2-10 mcg/min | IV infusion | Alternative |
Key Points
- Treat only if symptomatic (hypotension, AMS, shock, chest pain)
- Atropine is ineffective for transplanted (denervated) hearts
- High-degree AV blocks (Mobitz II, 3rd degree) usually need pacing
- Do not delay pacing for patients with poor perfusion
- Identify reversible causes: medications (beta-blockers, CCBs), hyperkalemia, hypothyroidism
ACLS Tachycardia with PulseUrgent
cardiac
Steps
1
Assess stability
Is the patient hemodynamically unstable (hypotension, AMS, chest pain, acute HF)?
YESImmediate synchronized cardioversion (Step 2)
NOIdentify rhythm type (Step 3)
2
Synchronized cardioversion (unstable)
Sedate if conscious (midazolam, etomidate, propofol)
- Narrow regular: 50-100J
- Narrow irregular (A-fib): 120-200J biphasic
- Wide regular: 100J
- Wide irregular: Defibrillation dose (DO NOT synchronize)
3
Identify rhythm type (stable patient)
Is QRS narrow (<0.12 sec) or wide (≥0.12 sec)?
YESNarrow complex → Step 4
NOWide complex → Step 5
4
Narrow complex tachycardia
- Regular: Likely SVT → Vagal maneuvers first
- Adenosine 6 mg rapid IV push (followed by flush)
- If no conversion: Adenosine 12 mg rapid IV push
- If refractory: Diltiazem 15-20 mg IV or beta-blocker
- Irregular: Likely A-fib → Rate control (diltiazem, beta-blocker)
5
Wide complex tachycardia
If uncertain whether SVT or VT, treat as VT
- Regular: Assume VT until proven otherwise
- Amiodarone 150 mg IV over 10 min
- Procainamide 20-50 mg/min (max 17 mg/kg)
- Irregular wide: A-fib with aberrancy vs pre-excitation
- If pre-excited A-fib (WPW): AVOID AV nodal blockers
Medications
| Drug | Dose | Route | Timing |
|---|---|---|---|
| Adenosine | 6 mg | Rapid IV push | 1st dose for SVT |
| Adenosine | 12 mg | Rapid IV push | 2nd dose if needed |
| Amiodarone | 150 mg over 10 min | IV | Wide complex / VT |
| Diltiazem | 15-20 mg (0.25 mg/kg) | IV over 2 min | Rate control |
| Procainamide | 20-50 mg/min | IV | Max 17 mg/kg |
Key Points
- Unstable = immediate synchronized cardioversion
- Adenosine only for regular narrow complex (SVT)
- Adenosine must be given rapid IV push at proximal port with saline flush
- Assume wide complex tachycardia is VT until proven otherwise
- Avoid AV nodal blockers in pre-excited A-fib (WPW)
- Irregular wide complex without a pulse = defibrillate (VF)
Anaphylaxis ManagementCritical
emergency
Steps
1
Recognition
- Bronchospasm / stridor / upper airway edema
- Hypotension / cardiovascular collapse
- Urticaria / flushing / angioedema
- GI symptoms (nausea, vomiting, cramping)
- Onset typically within minutes of exposure
2
Stop trigger agent, call for help
Remove causative agent. Call for help and anaphylaxis kit.
3
Epinephrine (FIRST-LINE)
Do NOT delay epinephrine. It is the only first-line treatment.
- IM: 0.3-0.5 mg (1:1000) anterolateral thigh
- IV: 10-100 mcg boluses (1:100,000) for severe/refractory
- Infusion: 0.05-0.5 mcg/kg/min for persistent hypotension
- Repeat IM q5-15 min as needed
4
Volume resuscitation
Crystalloid (NS or LR) 20-30 mL/kg rapid bolus. May need 4-8 L in severe cases.
5
100% O₂ and airway management
- High-flow O₂ via face mask
- Early intubation if airway edema progressing
- Prepare for surgical airway if edema severe
6
Adjunct medications
Adjuncts are second-line. Do NOT delay epinephrine for these.
- Diphenhydramine 50 mg IV (H1 blocker)
- Ranitidine 50 mg IV or Famotidine 20 mg IV (H2 blocker)
- Methylprednisolone 125 mg IV (prevents biphasic reaction)
- Albuterol 2.5-5 mg nebulized (for bronchospasm)
7
Refractory anaphylaxis
- Vasopressin 1-2 units IV bolus
- Glucagon 1-5 mg IV (if on beta-blockers)
- Methylene blue 1-2 mg/kg IV (refractory vasoplegia)
Medications
| Drug | Dose | Route | Timing |
|---|---|---|---|
| Epinephrine | 0.3-0.5 mg | IM | Immediately, repeat q5 min |
| Epinephrine | 10-100 mcg | IV bolus | Severe cases |
| Diphenhydramine | 50 mg | IV | Adjunct |
| Ranitidine | 50 mg | IV | Adjunct |
| Methylprednisolone | 125 mg | IV | Prevent biphasic |
| Albuterol | 2.5-5 mg | Nebulized | For bronchospasm |
Equipment Checklist
- Epinephrine (1 mg/mL and diluted for IV)
- IV access (large bore, x2)
- Crystalloid fluids
- Airway equipment (prepare for difficult airway)
- Nebulizer for albuterol
Key Points
- Epinephrine is the ONLY first-line treatment — do not delay
- IM epinephrine is faster than SubQ and preferred for most patients
- IV epinephrine reserved for severe/refractory or intraoperative setting
- Observe for biphasic reaction (can occur up to 12-72 h later)
- Obtain tryptase level within 1-2 h of onset (confirms diagnosis)
- Patients on beta-blockers may have refractory hypotension (use glucagon)
Malignant HyperthermiaCritical
emergency
Steps
1
Recognition — early signs
- Unexplained rising ETCO₂ (most sensitive early sign)
- Tachycardia (unexplained, out of proportion)
- Masseter muscle rigidity (especially after succinylcholine)
- Generalized muscle rigidity
- Temperature rise (may be late sign, >1.5°C/5 min)
2
Stop ALL volatile agents and succinylcholine
Turn off vaporizers, remove from circuit if possible. Switch to TIVA (propofol, opioids).
3
Hyperventilate with 100% O₂
High fresh gas flow (≥10 L/min). Use new breathing circuit if available.
4
Dantrolene IV
Dantrolene 2.5 mg/kg IV bolus. Repeat every 5 min until symptoms resolve. Max initial: 10 mg/kg. Each vial needs 60 mL sterile water — assign multiple people to mix.
5
Active cooling
- Cold IV NS (not LR — hyperkalemia risk)
- Ice packs to axillae, groin, neck
- Cooling blanket
- Target temp <38.5°C; stop cooling at 38°C to prevent overshoot
6
Treat hyperkalemia
- Calcium chloride 10 mg/kg IV or Calcium gluconate 30 mg/kg IV
- Insulin 10 units IV + D50 50 mL IV
- Sodium bicarbonate 1-2 mEq/kg IV
7
Monitor and ICU admission
Call MHAUS Hotline: 1-800-644-9737
- ABG, K+, Ca²+, CK, myoglobin, lactate q6h
- Arterial line, Foley catheter
- Continue dantrolene 1 mg/kg q4-6h for 24-48h
- Watch for recrudescence (25% of cases)
Medications
| Drug | Dose | Route | Timing |
|---|---|---|---|
| Dantrolene | 2.5 mg/kg | IV bolus | Repeat q5 min to 10 mg/kg |
| Calcium chloride | 10 mg/kg | IV | For hyperkalemia |
| Insulin (regular) | 10 units | IV | With D50 for hyperkalemia |
| NaHCO₃ | 1-2 mEq/kg | IV | For acidosis |
Equipment Checklist
- Dantrolene (36+ vials of Dantrium or Ryanodex)
- Sterile water for reconstitution
- Cooling supplies (ice, cold fluids, blankets)
- Arterial line kit
- Foley catheter
- Point-of-care blood gas analyzer
Key Points
- Dantrolene is the ONLY specific treatment — do not delay
- Rising ETCO₂ is often the earliest sign
- Temperature rise may be a late finding
- Avoid calcium channel blockers with dantrolene (cardiac arrest risk)
- Recrudescence occurs in ~25% — ICU monitoring for 24-48h mandatory
- MHAUS 24/7 Hotline: 1-800-644-9737