Rapid Sequence Intubation
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Transcript Rapid Sequence Intubation
Intro to:
Objectives
Define RSI
Identify the Indicators for using RSI
Identify the relative contraindications and
disadvantages of RSI
Discuss the different roles in the RSI process
Review the crucial 7 P’s of RSI
Review the medications used during RSI
Review a difficult airway and identify
alternative tools and techniques
What is RSI?
Why RSI?
Respiratory failure
Inability to protect own airway
Impending or potential airway
compromise
GCS less than 8
Intractable seizures
Relative contraindications to RSI
Airway obstruction
Distorted anatomy
Major facial or laryngeal trauma
Angioedema
Disadvantages of RSI
Hypoxia if unable to complete intubation
RSI blocks the patient’s involuntary
reflexes and muscle tone in the
oropharynx and larynx
Adverse medication reactions
Masks underlying symptoms
Requires considerable amount of
training and recurrent training
The benefit of obtaining airway control
must always be weighed against the risk
of complications in these patients.
You are taking a breathing patient and
making them APNEIC
RSI Equipment
Airway equipment (ET, syringe, stylette,
etc)
Oxygen
Suction equipment
Ecg monitor
IV equipment
SaO2 monitor
Capnography
RSI meds
It’s a team effort!
Skilled intubator
Timekeeper/scribe
Vital sign monitor
Medication administrator
Assistant
Before you get started…. In the
ideal world
Get medical history
Obtain baseline neuro exam
Check all your equipment
Confirm pt. weight
7 Essential P’s of RSI
Preparation
Pre-oxygenate
Pre-medicate
Paralysis and Induction
Protection
Placement of the tube
Post Intubation management
Preparation
Prepare all equipment
including ETT, suction,
pulse oximeter, IV and
monitor
Position patient in sniff
position if C-spine
immobilization is not
indicated.
Pre-Oxygenate
Pre-oxygenate with 100% oxygen via
NRB for at least 3 min. or 8 vital
capacity breaths with 100% oxygen.
If ventilatory assistance is necessary
with BVM, be gentle and apply cricoid
pressure.
Do you predict a difficult airway?
Short neck or no neck
Small mandible
Obesity
Facial/maxillary trauma
Edema or infection
Degenerative spinal disease
What does a difficult airway
mean to you?
Be prepared!
Have plan B, C, and D if intubation fails.
Tools for a difficult airway
Have one ETT tube size smaller &
bigger available
ETTI (Bougie, Eshman, etc)
Back up devices (Combitube, King
airway)
Surgical airway kit
Are you ready?
What drugs do we use?
Oxygen
Ventilate while preparing for RSI
Lidocaine?
Atropine?
Versed
Etomidate
Succinylcholine
Vecuronium
Procedure
Pre-oxygenate – (NOT hyperventilate) for 2 – 3
min.
Assemble equipment
Proximal IV preferred
Connect pt. To monitor
Lidocaine (TBI)
Atropine (children < 10)
Versed
Etomidate
Succinylcholine
Sellick maneuver
Procedure, cont.
Stop ventilations
Observe for fasiculations
Intubate
If unable to ventilate in 20 sec. , stop and ventilate for
30 – 60 sec.
May give second dose of Sux (1 – 1.5 time initial dose
If bradycardia occurs, give Atropine and
hyperventilate
Confirm intubation
Attach Easy Cap or capnography device
Administer Vecuronium
MONITOR PATIENT
Protect the Patient
Maintain cervical stabilization prn
Maintain cricoid pressure until tube
placement is confirmed and secured.
Constant vigilance of monitoring
oxygenation
Whose tube is it?
The most experienced medic!
If unable to intubate within 20 seconds
or SaO2 drops below 92%, STOP and
ventilate with BVM
Confirm placement
Release cricoid pressure
How did you confirm the tube?
Gold standard (visualized tube passing
through the cords
Capnography
Mist in the tube
Bilateral breath sounds
Recheck tube placement after every patient
move, if airway resistance occurs or
increases, hear rate decreases, or O2
desaturation occurs
Post medication
Continue paralysis with Vecuronium
Continue sedation with Versed
Consider pain control
What if you can’t get the tube
in??
Provide 100% oxygen with BVM
Consider back up device
Consider surgical airway
All neuromuscular Blocking
Agents:
Work by blocking the natural
transmission of nerve impulses to
skeletal muscles.
No direct effect on Heart, Digestive
system, Brain, Pupillary response,
Smooth Muscle or other organ systems
No effect on mentation or pain
perception!
No direct effect on seizure activity.
Remember….
If performed correctly, RSI will take
between 7 – 10 minutes.
You are taking a breathing patient and
making them apneic.
Always be prepared and know your RSI
protocol.