JRCALC 2024 · DAS 2015 · Paramedic Scope of Practice
PREP
⚠ DIFFICULT AIRWAY — HAVE RESCUE PLAN READY
Pre-Hospital Intubation
Paramedic Scope — No RSI Drugs
This tool covers intubation within UK registered paramedic practice under JRCALC 2024. Neuromuscular blockade and induction agents (RSI) are NOT within standard paramedic scope. Intubation without drugs is indicated only in deeply unconscious or cardiac arrest patients with absent airway reflexes.
Patient Context
🫀
Cardiac Arrest
Apnoeic and areflexic — intubation indicated after initial BLS/ALS cycles
🧠
Deeply Unconscious — No Airway Reflexes
GCS 3–4, absent gag and cough reflex confirmed (OD, post-ictal, metabolic, head injury)
🩹
Major Trauma — Airway Compromise
Unconscious trauma patient with unprotected airway and absent reflexes
Patient Age
Step 1 Indications & Airway Assessment
Paramedic Indications (JRCALC 2024)
When Intubation is Appropriate
Cardiac arrest — after initial BLS/ALS cycles; do not interrupt CPR for intubation
GCS 3–4 with confirmed absent airway protective reflexes (no gag, no cough to suction)
Deeply unconscious patient where BVM or iGel has failed to maintain adequate oxygenation
Anticipated complete airway obstruction as a bridge (severe angioedema, inhalation burns)
Do Not Intubate If Reflexes Present
Any coughing, gagging or swallowing response means the patient is NOT suitable for paramedic intubation without drug assistance. Use iGel as the preferred airway device. Attempted intubation in a patient with intact reflexes risks laryngospasm, vomiting, and aspiration.
Difficult Airway — LEMON Assessment
L
L — Look externally: Obesity, short neck, receding jaw, large tongue, facial/neck trauma, beard, trismus
E
E — Evaluate 3-3-2: Mouth open <3 fingers · Hyoid-to-chin <3 fingers · Thyroid-to-floor <2 fingers
M
M — Mallampati: Tongue appears to fill mouth, soft palate not visible — predict difficult view
O
O — Obstruction: Stridor, angioedema, supraglottic mass, blood/vomit in airway, foreign body
N
N — Neck mobility: C-spine immobilisation, rheumatoid, ankylosing spondylitis, collar in situ
⚠ Difficult Airway — ≥2 LEMON Factors Present
Have iGel immediately to hand before attempting laryngoscopy. Consider iGel as first-line device. If proceeding: use bougie on first pass, limit to 2 attempts, then declare failed airway and insert iGel.
C-Spine
MILS Required Throughout
Dedicated second person for manual inline stabilisation. Remove front of collar only. Jaw thrust — avoid neck extension. Video laryngoscopy preferred if available.
Step 2 Equipment & Tube Size
Adult ETT Size
Patient
ETT ⌀ (ID mm)
Depth at Lips
Adult ♀
7.0–7.5
21–22 cm
Adult ♂
7.5–8.0
22–23 cm
Burns / Trauma
7.0 minimum
21–22 cm
Paediatric ETT Size
Formula
Uncuffed: (Age ÷ 4) + 4 · Cuffed: (Age ÷ 4) + 3.5 · Depth at lips (cm): ETT size × 3
Age
Uncuffed ⌀
Cuffed ⌀
Depth (lip)
<1 yr
3.0–3.5
3.0
9–10 cm
1 yr
3.5–4.0
3.0
10–11 cm
2 yr
4.0–4.5
3.5
11–12 cm
4 yr
4.5–5.0
4.0
12–13 cm
6 yr
5.0–5.5
4.5
14–15 cm
8 yr
5.5–6.0
5.0
16–17 cm
10 yr
6.0–6.5
5.5
17–18 cm
12 yr
6.5–7.0
6.0
18–19 cm
Intubation Circuit — Tap Each to Confirm
🔵
Endotracheal Tube (ETT)
Cuff integrity checked · lubricant applied · stylet shaped if used
PENDING
🔩
Catheter Mount
15 mm connector — ETT to filter / capnography
PENDING
🔶
HME Filter
Heat-moisture exchanger · bacterial/viral filtration in circuit
PENDING
📈
EtCO₂ Capnography Adaptor
Inline waveform capnography — connected and zeroed
PENDING
💨
BVM / Ventilator
O₂ at 10–15 L/min · circuit patent · PEEP valve if available
PENDING
ETT → Catheter Mount → HME Filter → EtCO₂ Adaptor → BVM
Monitoring: SpO₂ · ECG · EtCO₂ · NIBP — all attached and reading
IV / IO access confirmed patent
Step 3 Pre-Oxygenation & Positioning
Target SpO₂ ≥98% Before Attempting
Every 1% rise in SpO₂ above 95% extends the safe apnoea window. Do not rush this step. A well-oxygenated patient tolerates a failed first attempt far better than one who is borderline.
20° head-up where possible — reduces aspiration risk and improves glottic view
Aspiration Risk
High Aspiration Risk
Suction immediately available and tested. Head-up position if achievable. Aim for single, smooth, rapid intubation attempt. If vomiting occurs — suction immediately, left lateral tilt, re-attempt when airway is clear.
Pre-Attempt SpO₂
⚠ Hypoxia — Proceed with Extreme Caution
SpO₂ <94% — hypoxia will worsen during laryngoscopy. Consider whether iGel + BVM can maintain adequate oxygenation and defer intubation. If proceeding: one attempt only, return to BVM immediately if unsuccessful.
Grade III/IV — Bougie Technique
Pass bougie blindly along posterior tracheal wall. Feel for tracheal rings (clicks) and hold-up at carina (25–30 cm). Railroad ETT over bougie. Consider BURP (Backward Upward Rightward Pressure). Grade IV — escalate to failed airway plan immediately.
Attempt Log
Maximum 3 Attempts — Oxygenate Between Each
Each subsequent attempt must modify technique, operator, or patient position. At 3 attempts: stop, declare failed airway, insert iGel.
Inflate cuff with 5–10 mL air. Stop when no audible leak during ventilation. Target cuff pressure 20–30 cmH₂O if manometer available. Note and record cm marking at teeth/lips.
Step 5 Tube Confirmation
⚠ Undetected Oesophageal Intubation is Fatal
No single method is 100% reliable. Waveform capnography is gold standard — a consistent rectangular waveform over 6 consecutive breaths confirms tracheal placement in a perfusing patient.
Gastric CO₂ washout — value falls with each breath and disappears. REMOVE TUBE.
❌
Absent / Flat Waveform
Oesophageal intubation or equipment failure. Treat as oesophageal — REMOVE TUBE.
5-Point Auscultation
Epigastrium — silent (gurgling = oesophageal)
Left apex — air entry present
Right apex — air entry present
Left base — air entry present
Right base — air entry present
⚠ Right Main Bronchus Intubation
Reduced or absent air entry on the left with good entry on the right — tube is too deep and has advanced into the right main bronchus (it takes off at a shallower angle than the left). Do not remove the tube — deflate cuff, withdraw 1–2 cm, re-inflate, re-auscultate. Confirm depth at teeth against pre-planned measurement. This is the most common malposition after cardiac arrest when depth is not checked.
Additional Confirmation
Bilateral equal chest rise with each ventilation
SpO₂ maintaining or improving post-intubation
Condensation visible in tube on expiration
Depth at teeth matches pre-planned depth (__ cm)
Colorimetric CO₂ detector — colour change if waveform capnography unavailable
Tube Security
Tube secured — tie / Thomas holder / Mefix · depth noted on tape
C-spine precautions maintained / collar replaced if applicable
Accept permissive hypercapnia — prioritise avoiding barotrauma over normalising CO₂
Sudden deterioration post-intubation → work through DOPE below
DOPE — Sudden Deterioration Post-Intubation
D
Displacement — Tube moved up (extubation) or down (right main bronchus). Reconfirm depth at teeth, re-auscultate bilaterally. Reduced left air entry = too deep → deflate cuff, withdraw 1–2 cm, re-inflate, recheck
JRCALC Paramedic Drugs — Post-Intubation Context
RSI agents are not within scope. The following are available to a UK registered paramedic under JRCALC and may be appropriate once the patient is intubated:
Analgesia / Sedation if signs of awareness
Morphine 0.1 mg/kg IV — titrated
Signs of awareness: rising HR / BP / movement · Titrate 2–4 mg increments · Monitor for hypotension · JRCALC paramedic indication
Sedation — check local NWAS SOP / PGD before use
Midazolam 1–2 mg IV increments
Titrate to effect · Caution in haemodynamic compromise · Confirm local authorisation
Bradycardia — vagal response to laryngoscopy / tube
Atropine 500 mcg IV
Repeat to maximum 3 mg · Standard JRCALC paramedic cardiac drug
Step 7 Monitoring & Transfer
Minimum Monitoring Post-Intubation
Continuous waveform EtCO₂ visible at all times — target 4.7–6.0 kPa
SpO₂ with waveform — target 94–98%
12-lead ECG if post-arrest or cardiac cause
NIBP every 5 minutes minimum
GCS / pupils recorded at last conscious assessment (pre-intubation)
Blood glucose checked
Temperature if prolonged scene / hypothermia concern
IV / IO patent and secured for transport
Pre-Alert & Transfer
Pre-alert to ED / ITU — state intubated, ETT size, depth, EtCO₂, drugs given, context
ETT depth noted on tube and documented on PCR
All drugs: name · dose · route · time on PCR
Number of intubation attempts documented
Cormack-Lehane grade documented
Rescue equipment accessible in vehicle (iGel, suction, BVM)
SBAR handover given face-to-face to receiving team
⚠ FAILED Airway Algorithm
🚨 Failed Airway Declared
3 attempts reached OR SpO₂ cannot be maintained between attempts. Prioritise oxygenation over intubation at all times.
Step 1 — Oxygenate Immediately
Two-Person BVM
Insert oral and/or nasal airway adjuncts
Jaw thrust + head tilt (unless C-spine concern)
Two-hand EC grip mask seal — second person squeezes bag
PEEP valve if available · 10–15 L/min O₂
Step 2 — Insert iGel
iGel Size Guide
Size 1<5 kg
Size 1.55–12 kg
Size 210–25 kg
Size 2.525–35 kg
Size 330–60 kg
Size 450–90 kg
Size 5>90 kg
Lubricate · Insert along hard palate to resistance · Confirm with EtCO₂ waveform and chest rise
Step 3 — CICO (Cannot Intubate Cannot Oxygenate)
🚨 CICO — SpO₂ Falling Despite BVM + iGel
Emergency front of neck access (eFONA) required. Act immediately.
Scalpel-Bougie Cricothyroidotomy
Identify cricothyroid membrane (CTM) — midline, between thyroid and cricoid cartilage
Stabilise larynx — laryngeal handshake with non-dominant hand
Horizontal stab incision through skin and CTM with size 10 scalpel blade
Hook trachea caudally / dilate with finger or tracheal hook
Insert bougie caudally — feel for tracheal rings / hold-up at carina