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There is a dearth in literature when it comes to defining the
role of the emergency nurseduring rapid sequence induction and
endotracheal intubation. However, from experienceworking in
accident and emergency one can say that there are certain vital
things theemergency nurse is responsible for.
Before RSI and ET intubation, the emergency nurse should make
sure that all theequipment, which may be required during the
procedure, is functioning properly andreadily available. This
includes the wall mounted oxygen point, suctioning unit andadjuncts
as well as self and oxygen inflating bags, different types and
sizes of masks,circuits, laryngoscope handles in addition to
straight and curved blades in different sizes,endotracheal tubes
(size according to the APLS formula [(age +4) / 4], one size
smaller and one larger), tape to fix the tube, stethoscope, carbon
dioxide detectors and monitor (with all required leads for ECG,
Spo2, CO2, etc.) and all the other equipment listed
previously in (AAAAAA). All the above mentioned should be
routinely checked by thenurse in charge of the resuscitation
area.
It is good practice and in most cases the anaesthetic doctor
will withdraw the drugsrequired and have them prepared. However,
the emergency nurse has to make sure thatthe drugs required for RSI
and the respective reversal agents are available if required.
From experience, it is wise and of best practice to assign a
specific emergency nurse toassist the anaesthetist during the
procedure. This will make sure there is a continuation of care as
the nurse is responsible in the pre, during and post-intubation
periods. Ideally, thenurse should have prior experience in
assisting during endotracheal intubation in order to
provide the best quality of care.
Having all the equipment readily available the next thing is the
proper positioning of
the patient. Depending on the age and size of the patient, the
nurse should use adjuncts -such as a rolled towel underneath the
patients shoulders and back to make the patientsairway as easily
accessible for endotracheal intubation as possible.
After good communication between the anaesthetist and the nurse
and the rest of the team the anaethetist will then proceed to
induce anaesthesia. At this stage, it is theresponsibility of the
nurse to follow the anaesthetists instruction step by step. The
nurseshould then perform cricoid pressure this flattens the
oesophagus and gives theanesthetist a better view of the trachea.
One should never release cricoid pressure untilthe anaesthetist
asks to - this ensures that there is no risk of gastric content
aspiration.However, if the person performing the cricoid pressure
feels that the patient is about tovomit, it is the only instant
when it is advisable to release (REFERENCE).
At this stage the anaesthetist would have pre-oxygenated the
patient, inserted thelaryngoscope in position and the nurse would
be holding cricoid pressure. The nurseshould have suctioning
equipment at hand suctioning performed as required - and theright
size endotracheal tube should be handed to the anaesthetist when
asked to. Once thetube is inserted and position checked
(auscultation of lung fields and stomach) the nurseshould release
the cricoid pressure when asked to and secure the tube using tape
or tube
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holder. If a cuffed tube is being used, the nurse should inflate
the cuff using a syringe. ACO2 detector should be attached to the
end of the tube and connected to continuousmonitoring. The position
of the tube is finally confirmed by a chest x-ray.
With the tube in position, continuous ventilation can be
performed and the patient can be
even connected onto a ventilator, if the equipment is available.
It is the anaesthetistsresponsibility to set the ventilator to the
desired settings.
It is the nurses responsibility to regularly check that the
patient is being adequatelyventilated while assessing the airway
and breathing. The nurse is responsible to ensurethat the tube does
not get dislodged (especially if the patient is being shifted from
thetrolley onto a bed or table if a CT or surgery is required). In
addition, suctioning should
be performed regularly and tape changed whenever required.
