Rapid Sequence Induction

• “Virtual simultaneous administration, after

preoxygenation, of a potent sedative agent

and a rapidly acting neuromuscular

blocking agent to facilitate rapid tracheal

intubation without interposed mechanical

ventilation” Ron Walls, MD

» Manual of Emergency Airway Management

“To Intubate or not to Intubate?”

6 questions to ask:

• Can the patient maintain an airway?

• Can the patient protect this airway?

• Is the patient appropriately ventilating?

• Is the patient appropriately oxygenating?

• Is the patient’s condition likely to deteriorate?

• Is the scene appropriate: safety, moving the patient

while apneic

Examples of RSI Indications

• Conditions requiring oxygenation/ventilation control or positive pressure ventilation:

– Traumatic brain injury with ALOC

– Severe thoracic trauma (flail chest, pulmonary contusions with hypoxemia)

– Clinical condition expected to deteriorate

• Unconscious or ALOC with potential for or actual airway compromise or vomiting

• And patient has……

– A clenched jaw

– An active gag reflex

Complications• Increased intracranial pressure

• Increased intraocular pressure

• Increased intragastric pressure

• Aspiration due to decreased gag reflex

• Malignant hyperthermia

• Dysrhythmias

• Hypoxemia

• Airway trauma

• Failure to intubate / failure to ventilate

• DEATH

• Medication induced or procedural?

3 Major Assumptions of RSI

1. The patient has a full stomach

2. The Paramedic can secure an airway

Failure = DEATH for the patient

DO NOT take away what you cannot give back!

3. The Paramedic can resuscitate the patient

Equipment & Knowledge readily available

Key Question

• BVM

– Difficult Airway Protocol

– Crash Airway Protocol

– Failed Airway Protocol

KISS

• Simplicity - limits complications and death

– Limit number of steps/meds

– Rapid onset

– Hemodynamically stable or minimal impact

Preparation is the KEY

for an organized,

smooth intubation

Proper Prior Planning Prevents Piss Poor Performance

Remember the 7 P’s!!

RSI 7 Ps

• Prep

• PreO

• Pretreat

• Paralysis

• Protection/Positioning

• Placement with Proof

• Postintubation Management

Assess the Risks

Some Predictors of a Difficult

Airway• C-spine immobilized trauma

patient

• Protruding tongue

• Short, thick neck

• Prominent upper incisors

(“buckteeth”)

• Receding mandible

• High, arched palate

• Beard or facial hair

• Dentures

• Limited jaw opening

• Limited cervical mobility

• Upper airway conditions

• Face, neck, or oral trauma

• Laryngeal trauma

• Airway edema or obstruction

• Morbidly obese

Additional Predictors:

Medical History• Joint disease

• Acromegaly

• Thyroid or major neck surgeries

• Tumors, known abnormal structures

• Genetic anomalies

• Epiglottitis

• Previous problems in

surgery

• Diabetes

• Pregnancy

• Obesity

• Pain issues

Prep

Assess potential difficulties

• MOANS• Mask seal

• Obesity/Obstruction

• Age > 55

• No teeth

• Stiff

• LEMON

– Look

– Evaluate 3-3-2

– Mallampati

– Obstruction

– Neck mobility

So, give me some good news:

The 3-3-2 Rule

• Bottom of Jaw/Chin to Neck > 3 fingers

> 7cm usually a sign of easy intubation

< 6cm is an indicator of a difficult airway

• Jaw/Palate > 3 fingers wide

• Mouth opens > 2 fingers wide

Any single indicator has poor specificity

Paralysis with Induction

• Ketamine

– Sedation• 50mg/ml

Rocuronium

(Zemuron)

– Paralytic

• 10mg/ml

Rocuronium (Zemuron)

• Very similar properties to

Vecuronium

• Does not need to be

reconstituted, can be stored at

room temp for 60 days

• Less vagolytic properties

Rocuronium

• Onset: 30-60 seconds

– Fastest onset of all non-depolarizing NMBs

• Dose: 1 mg/kg IVP– 10mg/ml Vials of 100mg/10ml

• Duration: 20-75 minutes

• Maintenance dose is 1/2 the initial dose

Protection/Positioning

• Sellick?

• BURP?

– Falling out of favor?

• Tracheal positioning

“BURP”

• Backward, Upward,

Rightward Pressure:

manipulation of the trachea

• 90% of the time the best

view will be obtained by

pressing over the thyroid

cartilage

Differs from the Sellick Maneuver

Direct Visualization…

Placement with Proof

• View cords if possible

• End tidal CO2

Postintubation Management

• Secure tube

• Monitor VS

• Manage oxygenation

• Sedation, analgesia and paralysis

maintenance

• Rocuronium ½ Dose

• Ketamine ½ Dose

Always have a back-up plan.

• Plans “A”, “B”, and “C”

• Know the answers before you begin

Plan “A”: (ALTERNATIVES)

• Different:– Size of blade

– Type of blade• Miller

• Macintosh

• Specialty IE: McGrath

– Position (patient & provider)

• Hockey stick bend in ETT or Directional tip ETT

• Gum Elastic Bougie Endotracheal Tube Introducer

• Remove the stylette as you pass through the cords

• “BURP”

• 2-person technique

• OR Have someone else try

Plan “B”: BVM and BACKUP AIRWAY

• Can you ventilate with a BVM?

– (Consider two NPA’s and an OPA, + Cricoid pressure w/ gentle

ventilation)

• *****KING – LT********

King-LT? Is this appropriate?

What do we do when faced with a “Can’t

Intubate Can’t Ventilate” situation?

• Plan “C”: Last resort…

• (CRIC) Surgical

– Know the skill and equipment !!!

Failed Airway

Unable to intubate (including

blind devices) and unable to

ventilate with a BVM and

maintain an Sp02 > 90 %.

Failed Airway• Indication:

Inability to maintain oxygenation / ventilation after previous intubation

attempts

• Precaution:

Anticipation during previous airway procedures will allow for rapid

deployment of rescue airway or Cricothyrotomy

Cardiac Monitor, ETCO2 and Pulse Oximetry are recommended for all airway

attempts

• Technique:

Maintain oxygenation with 100% oxygen via non-rebreather mask

Passive oxygenation via nasal cannula at 15 lpm

Placement of a King LT Airway as a rescue device

If unsuccessful or unable to maintain oxygenation; perform Cricothyrotomy

• Complications and Special Notes:

Receiving facility should be notified and advised that you are managing a

Failed Airway

Final Thoughts on the

“Failed Airway”

• In all cases of a failed airway, the

Paramedic must continually assess the

adequacy of oxygenation and ventilation

• 7% of all trauma patients will require

intubation

Lets practice!

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