Rapid Sequence Intubation

In the Emergency Department

Rapid Sequence Intubation

RSI The use of medication to facilitate passing the

endotracheal tube Analgesics Sedatives Paralytics

CONTROLLED procedure Will take several minutes to accomplish Requires a team effort

The ultimate goal is to secure an airway without having the patient vomit and aspirate.

Indications for RSI

Impending airway obstruction Facial fractures…no excessive oral bleeding Facial burns…inhalation injury Expanding retropharyngeal hematoma

Excessive work of breathing Example…the exhausted asthmatic

Shock GCS <8 Persistent hypoxia (<90%)

6 P's of RSI

Preparation Preoxygenation Pretreatment Paralysis (with induction) Placement of the tube Post intubation management

Preparation

Oxygen Source Suction Equipment Endotracheal tubes Bag-valve-mask

device Glidescope Cardiac Monitor

Pulse oximeter End-tidal CO²

monitor Temperature probe

(LONG TERM) Alternative airway

equipment-laryngeal mask airway or jet ventilator or crich tray

Preparation

Assign roles and responsibilities Leader Intubationist Cricoid pressure Monitoring Medications Documentation

2. Preoxygenate

3-5 minutes with 100% O2 bag mask to ensure adequate oxygen reservoir in lungs during apnea

Assure age appropriate fitting mask

3. Pre-treatment

Laryngoscopy causes stimulation of afferentreceptors in the posterior pharynx,hypopharynx and larynx.

Reflexes can cause:– Increased intracranial pressure (ICP)– Stimulation of upper & lower respiratory tract

increasing airway resistance.– Stimulation of autonomic nervous system, with increase heart rate and BP (vagal stimulation cause decrease in pediatric!)

Pre-treatment

Attenuate (weaken) normal physiologic &

pathophysiological reflex responses

caused by airway manipulation during

laryngoscope and insertion of an

endotracheal tube.

- Lidocaine

- Atropine

- Defasiculating agent

Pre-treatment meds

Atropine – Treats brady response to SUX, and in young children.

Lidocaine – Helps decrease ICP associated with intubation.

Vecuronium (defasiculationg dose)- keeps muscles from fasiculating (twitching) when using “Succs”

4. Paralysis (with induction)

Check patency of line first! Make sure everyone is ready Give IV pushes rapidly and flush Anesthesia before paralysis! *Induction agent is followed immediately

by the paralytic without waiting to see if ventilation can be maintained

Hallmark of RSI

Anesthesia

Etomidate Short acting sedative

hypnotic Dose=0.3 mg/kg Induction time= 5-10

min. *Myoclonus

Ketamine

IM or IV Dissociative

anesthesia Dose = 1-2 mg/kg

(IV)/ 4-10mg/kg IM Lasts approx. 30”

Glazed eyes & nystagmus

Watch for agitated recovery

*Increased BP, HR,tonic/clonic,N/V, hypersalivation

Anesthesia

Versed Benzodiazepine, Sedative 1-2 mg IV Onset 1.5 min. to 2H *Hypotension

Anesthesia

Fentanyl Narcotic analgesic 50-100 mcg/kg Lasts 30 min. *Resp. depression

Propofol (Diprivan)

Induction agent Standard dose: 2

mg/kg Rapid onset, short

duration Considerations:

*Hypotension,apnea

Paralytic (Neuromuscular block) VECURONIUM

Skeletal Muscle Relaxer

0.1 MG/KG IV(PARALYZING DOSE)

Lasts 25 to 45 min.

Paralytic

SUCCINYLCHOLINE Neuromuscular

blocking agent Dose: 1 mg/kg Duration: 5 min.

Side effects: Fasciculations,

muscle pain,rhabdo, hyper K, brady, vent. Dysthythmias

Malignant Hyperthermia

Paralytic

Contraindications – Personal or family

history of malignant hyperthermia – Significant, verified,

hyperkalemia is an absolute contraindication – End-stage renal

disease / dialysis dependent

patients with unknown potassium level

5. Placement of Tube

Position patient

• Do not bag unless SpO2 < 90%

• Sellick’s Maneuver (Cricoid pressure)

Placement of tube

Placement and Proof

Confirm tube placement

– ETCO2 – Bilateral breath

sounds – Absent epigastric

sounds

Failed attempt

What if the intubation attempt is not

successful? 1st step = bag/mask ventilation for

support

Rescue Maneuvers – The first rescue from failed intubation is

bagging – The first rescue from failed bagging is better

bagging

6. Post-intubation Management

Secure tube ETCO2 Chest x-ray Long acting sedation (+/- paralysis) – Midazolam 0.2mg/kg – Propofol 25-50μg/kg/min Establish ventilator parameters

6P’s RSI Summary

• Preparation (zero – 10 minutes)

• Preoxygenation (zero – 5 minutes)

• Pretreatment (zero – 3 minutes)

• Paralysis with induction (time zero)

• Positioning (zero + 30 seconds)

• Placement (zero + 45 seconds)

• Post-tube management (zero + 90 seconds)

Questions?