Transcript Rapid Sequence Intubation - Louisiana State University

Rapid Sequence Intubation
Neil Laws
CareFlite Ft. Worth
Objectives
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Indications
Contraindications
Complications
Pharmacology
Procedure
Indications
• Patients who cannot tolerate awake
intubations.
• Combative patients with compromised
airways.
• Patients with depressed LOC
• Severe head trauma with the need for
airway control and hyperventilation.
Indications
• Need to decrease myocardial oxygen
demand.
• Uncontrolled seizure activity
• Status asthmaticus nearing respiratory arrest
• Anytime risk for potential/actual airway
compromise is suspected.
Absolute Contraindications
• Patients in whom Cricothyroidotomy would
be difficult or impossible:
– Children less than 2 years of age
– Massive neck swelling/injury
• Patients who would be difficult/impossible
to intubate:
– Acute epiglottitis
– Upper airway obstruction
Relative Contraindications
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Known hypersensitivity to the drug
Penetrating eye injuries
History of malignant hyperthermia
Hyperkalemia
Unstable fractures
Complications
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Increased intragastric pressure
Bradycardia/Asystole
Malignant hyperthermia
Prolonged apnea
Inability to intubate/ventilate
Hypotension
Aspiration
Increased intraocular pressure
Preparation
• Assemble necessary equipment (suction,
BVM, working laryngoscope and
appropriate sized ET tube, drugs/syringes,
pulse oximeter, cardiac monitor, O2)
• Assure at least one well running IV line
• Connect patient to pulse ox and monitor
• Assign duties (cric pressure, pushing of
meds, bagging, etc.)
• Position patient properly
Oxygenation
• It is ideal to let the
patient spontaneously
breathe 100% O2 for
4-5 minutes to wash
out the nitrogen
reservoir and establish
an oxygen reservoir.
• If the patient is not
breathing adequately,
or you are unable to
wait 4-5 minutes, 4
vital capacity breaths
are adequate. 1-2
minutes of
preoxygenation with
100% O2 is preferred.
Pharmacology
Medications used in RSI
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Lidocaine
Versed
Valium
Atropine
Anectine / Succinylcholine
Norcuron / Vecuronium
Lidocaine
• Lidocaine is used in the RSI setting 2-3
minutes prior to intubation to control ICP in
patients with possible head injuries, patients
with CNS pathologies (hypertensive crisis,
or bleed), and dysrhythmia control
• Dosage: 1.5 mg/kg IVP
• Pedi dosage: 1.5 mg/kg IVP
Versed
• Versed is one agent used to sedate the
patient and also to achieve an amnesic
effect. It is a short acting Benzodiazepine
that has sedative and anesthetic properties.
Versed will depress the respiratory system.
• Benzodiazepines are contraindicated in the
presence of hypotension.
• Dosage: 5 mg IVP
• Pedi dosage: 0.1 mg/kg IVP
Valium
• Valium is also a short acting
Benzodiazepine that is used to sedate the
RSI patient prior to administration of the
paralytic agent. Valium does not seem to
have the same amnesic effects of Versed.
• Valium does depress the respiratory system.
• Dosage: 5 mg IVP
• Pedi dosage: 0.2 mg/kg IVP
Atropine
• Atropine is used on the adult patient
exhibiting bradycardia.
• Atropine is given prophylacticly to pediatric
patients less than 8 years old.
• Dosage: 0.5 mg IVP
• Pediatric dosage: .01-.02 mg/kg
Succinylcholine
• Will be used to induce paralysis in adults
and children.
• Short acting depolarizing neuromuscular
blocking agent that relaxes and paralyzes
skeletal muscle
• Has NO effect on pain threshold or LOC
• Muscle fasiculations are a potential problem
• Dosage: 1.5 mg/kg IVP
• Pedi dosage: 2.0 mg/kg in pedi pt. <3 y/o
Norcuron
• Norcuron is a non-depolarizing
neuromuscular blocking agent that is used
to maintain paralysis of the patient ONLY
after the absolute confirmation of correct
tube placement.
• Several indicators should be used to
confirm placement.
• Dosage: 0.1 mg/kg IVP Adult and Pedi
• Repeat dosage: .05 mg/kg IVP
Procedure
Procedure
• Preoxygenate patient with 100% O2 by
non-rebreather mask or by BVM as patient
condition permits
• Premedicate as is appropriate:
– Lidocaine
– Versed / Valium
– Atropine
Procedure
• Administer Succinylcholine
• Apply cricoid pressure to occlude the
esophagus until intubation is successfully
completed and the cuff is inflated.
• Continue to oxygenate the patient with
100% O2 for 1-2 minutes allowing sedation
to take effect. Jaw relaxation and decreased
resistance to manual ventilation's are
indicators that the patient is ready to be
intubated.
Procedure
• Be prepared to suction
• Perform a controlled intubation with in-line
stabilization, if indicated.
• Confirm placement of tube, secure.
• If intubation is unsuccessful, remove tube
and ventilate the patient with 100% O2
(hyperoxygenate) until ready to re-attempt
Procedure
• It may be necessary to re-medicate the
patient with succinylcholine.
• Maintain C-spine immobilization
• If repeated intubation attempts fail, ventilate
the patient with 100% O2 via BVM until
spontaneous respiration's return, or if you
are unable to adequately ventilate the
patient you will need to perform a
cricothyroidotomy.
Procedure
• Once intubation is completed and tube
placement is confirmed, inflate the cuff,
release cric pressure, secure the tube, note
tube depth for documentation, all while
continuing to ventilate with 100% O2.
• Following confirmation of intubation,
administer 0.1 mg/kg vecuronium
(Norcuron) IVP.
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• It is important to note that once a
neuromuscular blocking agent is given, the
paramedic assumes complete responsibility
for maintaining an adequate airway and
ventilations. O2 sats and ETCO2 levels
must constantly be monitored. The
paramedic must always be prepared to
perform a surgical airway if intubation
cannot be done, and ventilation with a BVM
is no possible.