Airway and RSI Questions on the Paramedic Exam: What to Know

What airway and RSI questions on the paramedic exam test

The National Model EMS Clinical Guidelines describe airway care as an escalation: open and clear the airway, add an oral or nasal airway, ventilate with a bag-valve mask, consider noninvasive ventilation, then a supraglottic airway, then intubation, and a surgical airway only when oxygenation cannot be maintained any other way. Exam items are built on that ladder. The right answer is usually the least invasive step that will work now, not the most advanced skill on the list.

• Recognize the patient who needs ventilation, not just oxygen: falling mental status, slow or shallow breathing, rising end-tidal CO2.
• Bag well: two-person, two-thumbs-up seal, just enough volume for chest rise, 10 to 12 breaths a minute for an adult, with PEEP starting around 5 cm H2O.
• Know when an advanced airway is indicated and when it is not, including the guideline point that pediatric intubation has unclear benefit in the field.
• Keep peri-intubation hypoxia (SpO2 under 90%) and hypotension from happening, since the guidelines track both as quality measures.

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Airway assessment: predicting a difficult airway

Before any drug is drawn up, the exam expects you to ask two questions: will laryngoscopy be hard, and will bag-mask ventilation be hard? Two mnemonics answer them, and items often test whether you match the right one to the right task.

The NASEMSO guideline lists the same warning signs in plain terms: a short jaw or limited jaw thrust, small thyromental space, large tongue, obesity, large neck, facial hair, prior neck surgery, trismus, and traumatic injuries to the face, neck or chest. A scenario that mentions any of these is telling you to plan for failure before the first attempt, with a bougie, a supraglottic airway and a surgical kit ready.

Preoxygenation and apneic oxygenation

Preoxygenation fills the lungs with oxygen so the patient tolerates the apnea of RSI. The traditional end points are 3 minutes of tidal breathing on high-concentration oxygen or eight vital-capacity breaths through a tight-fitting mask. Noninvasive ventilation can improve oxygenation before intubation in some patients with respiratory failure, and a nasal cannula left on high flow during the attempt (apneic oxygenation) may lengthen the time before desaturation.

• Elevate the head when possible; positioning improves both mechanics and the view.
• Suction a soiled airway before the attempt; the guideline links this to first-pass success.
• Routine cricoid pressure is not recommended in adults or children.
• Resuscitate before you intubate: positive pressure after intubation lowers preload, so fix hypotension and hypoxemia first.

RSI drug choices and doses

The exam asks less about memorizing every dose and more about matching the drug to the patient. The table gives label ranges for adults; your agency protocol sets the doses you actually use, and many emergency RSI protocols use the higher end of the paralytic ranges.

Induction agent: etomidate or ketamine?

Ketamine is the classic exam answer for the patient in severe bronchospasm, and its label notes that it often raises heart rate and blood pressure. In the large RSI trial of 2,365 critically ill adults, ketamine and etomidate had similar 28-day mortality (28.1% vs 29.1%), but cardiovascular collapse during intubation was more common with ketamine (22.1% vs 17.0%). For a patient on the edge of shock, the better answer is often to resuscitate first and have a pressor ready, whatever the induction agent.

Paralytic: when succinylcholine is wrong

Succinylcholine can cause a dangerous potassium rise. Its label contraindicates it after the acute phase of major burns, multiple trauma, extensive denervation or upper motor neuron injury, and with malignant hyperthermia risk or skeletal muscle myopathy, and carries a boxed warning about hyperkalemic cardiac arrest in children with undiagnosed myopathy. When a stem mentions burns from several days ago, a stroke or spinal cord injury beyond the acute phase, neuromuscular disease or a missed dialysis run, rocuronium is the answer. Because rocuronium lasts far longer than any induction dose, post-intubation sedation and analgesia must follow promptly.

Confirming the tube with waveform capnography

The guideline calls waveform capnography the most reliable confirmation of an endotracheal tube or supraglottic airway, and says it should be attached before the first breath through the device. Breath sounds, chest rise and oxygen saturation are less reliable, colorimetric devices are less accurate than clinical assessment, and misting in the tube is not a reliable sign at all.

• Look for sustained exhaled CO2: a waveform that rises and falls with each breath, stays steady or grows over at least seven breaths, and peaks above 7.5 mm Hg.
• No sustained CO2 means the default is to remove the tube and reoxygenate. In every reviewed case of unrecognized esophageal intubation where the lungs were auscultated, breath sounds were reported as present.
• Keep capnography on for the whole transport and recheck after every patient move, because tubes are displaced during transfers.
• Note the tube depth at the teeth or gums and secure it with a commercial holder or tape.

The failed-airway plan

Exam items treat a failed attempt as a fork in the road, not a reason to try harder. The safe sequence is to stop, reoxygenate with a bag-valve mask or a supraglottic airway, change something before any further attempt (position, blade, video laryngoscope, bougie, operator), and limit the total number of attempts.

1. Attempt fails or SpO2 falls: stop and oxygenate by mask with adjuncts.
2. Mask ventilation is poor: place a supraglottic airway.
3. Cannot intubate and cannot oxygenate by any route: perform a surgical airway if trained, typically a scalpel-bougie-tube cricothyrotomy.
4. If a tube becomes dislodged in transport, a supraglottic airway is the guideline's fallback.

Difficult-airway guidelines stress that once it is clear the patient cannot be oxygenated, the surgical airway should not be delayed. Exam stems signal this with a falling saturation after failed intubation, failed bag-mask ventilation and a supraglottic airway that will not seat.

Sample questions: preoxygenation and a failed attempt

In the first question the patient is still breathing with a normal saturation, so there is time to prepare. Ask which option lengthens the safe apnea time. Giving the paralytic before the sedative is wrong on drug order, a 30-second preoxygenation wastes the window you have, and vigorous bagging after paralysis inflates the stomach. The option that combines full preoxygenation with oxygen flowing during the attempt is the only one that protects the saturation through laryngoscopy.

The second question tests the failed-airway reflex. The saturation has already dropped, so continuing the attempt trades oxygen for a chance at the tube, and a fixed saturation floor of 80% is not a safe target. Jumping straight to a cricothyrotomy skips the steps that may still work. Reoxygenating by mask and then changing the approach follows the escalation every airway algorithm uses.