Download ODEMSA Regional RSI Guidlines

Rapid Sequence
Intubation Regional
Guidelines
OLD DOMINION
Emergency Medical Services
ALLIANCE
Current January 2006
Regional Guidelines and Related Information
For Agencies Planning RSI Programs
In Planning Districts 13, 14, 15 and 19,
Old Dominion EMS Alliance Inc.
1463 Johnston-Willis Drive
Richmond, Virginia 23235-4730
Phone: 804-560-3300
Fax: 804-560-0909
www.odemsa.vaems.org
Preface
These Regional Rapid Sequence Intubation Guidelines were approved by the Old Dominion EMS
Alliance (ODEMSA) Medical Control Committee, and were implemented in November 2005. They are
intended to provide guidance to those advanced life support (ALS) agencies in the ODEMSA region that
are considering initiating a rapid sequent intubation airway management program under the direction of
its operational medical director (OMD). In publishing these guidelines, the Medical Control Committee
recognizes the need for alternate modes of airway management and the fact that ALS agencies must
adapt some procedures to meet unique local needs and requirements.
Therefore, these are minimal guidelines. The guidelines and related documents are designed to provide
a template by which agencies in the ODEMSA region will be able to meet a regional standard of care
while meeting those local needs and requirements. The agency OMD is welcome to enhance a rapid
sequence intubation (RSI) program. Please note, however, that whatever RSI program the agency
and its OMD develop must contain at a minimum all of the elements in these guidelines in order to
meet the regional standard of care as established by the ODEMSA Medical Control Committee.
Arthur C. Ernst, M.D., FACEP
ODEMSA Medical Director
Appreciation
These guidelines are the result of the combined efforts of three major EMS agencies and a major
teaching college in the Old Dominion EMS Alliance region. The primary document has been modified
from the RSI protocol created by the Henrico County Division of Fire at the direction of the Old Dominion
EMS Alliance Medical Control Committee. The Regional RSI Training Guidelines are based on those
developed by Hanover County Fire and EMS. Other elements and templates have come from those
developed by Chesterfield County Fire and EMS and several hospital emergency physicians. ODEMSA
and its member EMS agencies are indebted to these agencies, their chiefs, and individuals who have
contributed their time and expertise to developing and/or reviewing this document. These include:
Henrico County Division of Fire:
Chief Ronald Mastin, Chief of the Division
Robert G. Powell, M.D., FACEP, Operational Medical Director
R. D. McClure, NREMT-P, Assistant Chief
Kelly P. Schaaf, R.N. Quality Assurance Coordinator
Hanover County Fire and EMS:
Chief Fred G. Crosby, NREMT-P, Chief of Department
Randy P. Abernathy, NREMT-P, Deputy Chief
Jethro Piland, NREMT-P, Division Chief
Michael Watkins, NREMT-P, Training Officer
Chesterfield County Fire and EMS:
Chief Paul Mauger, Chief of Department
Allen Yee, M.D., FACEP, Operational Medical Director
John M. Kirtley Jr. NREMT-P, EMS/ALS Training Officer
John C. Greene, NREMT-P, EMS Med-Flight 1
VCU Medical Center:
Joseph P. Ornato, M.D., FACEP, Chair,
Emergency Medicine Department.
S. Rutherfoord Rose, Pharm.D., Director, Virginia Poison Center
Harinda Dhindsa, M.D., Medical Director, VCU LifeEvac
James H. Gould Jr., R.N., NREMT-P, Director, CT&CCE
Regional Rapid Sequence
Intubation Guidelines
Current January 2006
Contents
Section 1
RSI Regional Program Guidelines
Section 2
Regional RSI Training Guidelines
Section 3
A.
Suggested RSI Program Elements
B.
Recommended Medication-Facilitated Intubation
Protocol
Section 4
Regional RSI Drug Box Contents
Section 5
A.
Regional QA/QI Guidelines for RSI
B.
Recommended RSI Evaluation Form
C.
Glossary/Definitions
OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC.
1463 Johnston-Willis Drive
Richmond, VA 23235-4730
804-560-3300  FAX: 804-560-0909
www.odemsa.vaems.org
Rapid Sequence Intubation (RSI)
Section 1
Regional Program Guidelines
Planning Districts 13, 14, 15 and 19
Current January 2006
Scope:
These guidelines are intended for use only in circumstances/situations approved by
an EMS agency operational medical director (OMD) in a program endorsed by the
Old Dominion EMS Alliance’s (ODEMSA) Medical Control Committee. The
guidelines are designed to allow trained and cleared EMS providers the option of
managing patient airways with Rapid Sequence Intubation (RSI) in the ODEMSA
region. This document and related information will provide clear guidelines to
trained EMS providers about patient care requiring RSI, proper documentation, and
the essential quality assurance/quality improvement (QA/QI) review.
NOTE: RSI in the ODEMSA region will be performed only when there are at
least two (2) ALS providers cleared for intubation on the scene during the RSI
procedure. One of these providers must be an EMT- Paramedic cleared for
RSI. The ability to perform RSI in the ODEMSA region will be restricted to the
EMT-Paramedic level of certification.
These regional guidelines will apply to any patient that meets the patient profile in
Section IV of these guidelines.
I.
Definition:
Rapid Sequence Intubation, or RSI, is the use of pharmacological agents to facilitate
endotracheal intubation. Rapid sedation and paralysis using neuromuscular
blocking agents allows laryngoscopy and placement of an endotracheal tube in
those patients who fulfill the patient profile requirements.
II.
Purpose:
RSI is an organized approach to emergency intubation comprising rapid sedation
and muscle paralysis. Pharmacological paralysis facilitates endotracheal intubation
and maximizes the probability of successful placement of an endotracheal tube while
minimizing hemodynamic responses and complications.
NOTE: Neuromuscular blocking agents will not be given without first giving a
sedative agent to the patient!
A general overview of RSI involves: assessment of the patient; pre-oxygenation;
preparation of equipment and medications; sedation; cricoid pressure; muscle
relaxation; intubation; securing the airway; continuous reassessment; delivery of the
patient to the most appropriate medical facility; and completion of the quality
assessment/quality improvement (QA/QI) process.
III. Patient Profile:
The standard of airway control is orotracheal intubation using RSI as indicated for
the following patients:
1. Airway protection from hemorrhage, aspiration, edema, hematoma.
2. Airway protection for the unresponsive patient who may not be intubated
using standard airway management techniques. This altered level of
consciousness may be from injury, multiple trauma, burns, ingestion of
excessive medications, stroke, or infection.
3. Impending cardiac arrest due to respiratory fatigue and/or failure. This may
be
due to uncontrolled seizure activity, status asthmaticus, overdose, circulatory
shock secondary to trauma or infection, or combative patient.
4. Failure to appropriately ventilate/oxygenate a patient with other conservative
resources.
5. Any patient who demonstrates a decreasing ability to self-ventilate or selfoxygenate during the initial assessment or subsequent reassessment(s).
IV.
Patient Exclusion Criteria:
1. Any patient under age 14 and/or weighing less than 45 kgs.
2. Any patient who has spontaneous respirations with adequate
ventilation/oxygenation and a protected airway.
3. Any patient where intubation may not be successful due to airway obstruction
or trauma (i.e. epiglottitis, major facial/laryngeal trauma with significant edema
or distortion of facial/airway anatomy).
4. Upper airway obstruction.
5. Any patient with known hypersensitivity to RSI drugs.
V. Relative Contraindications:
1.
Any patient with known hyperkalemia.
2. Any patient with penetrating eye injuries.
3. Any patient with a history of malignant hyperthermia.
4. Any patient with myasthenia gravis.
VI. Recognized Potential RSI Complications:
1.
Inability to secure the airway after paralytic administration.
2.
Dysrhythmias.
3.
Aspiration.
4.
Tachycardia.
5.
Bronchospasm.
6.
Increased intracranial pressure.
7.
Inability to recognize decreased neurological status.
8.
Hypoxia.
9.
Cardiac arrest.
VII. EMS Provider Profile:
Initial: EMS providers who meet the following criteria will be cleared to perform RSI:
1.
EMT-Paramedic certification with documented one (1) year of experience
as a cleared advanced life support (ALS) provider.
2.
Three (3) documented successful live intubations within the last year, or
special clearance by the agency OMD after personal observations of
airway management techniques in the lab or OR/ED.
3.
Completion of a training program that incorporates all elements of these
Regional RSI Guidelines and is endorsed by the ODEMSA Medical
Control Committee.
4. A passing score on a regional written test administered during the training
program, as well as satisfactory completion of the RSI clinical lab instruction
and testing.
5. A RSI authorization form signed by the provider’s OMD, maintained by the
agency’s quality assurance coordinator, and updated every 12 months.
Recertification: Successful completion of a recertification program, which includes
both didactic and practical components to the process (approximate four (4) hour
course). This program requires special training, extra care in documentation and
participation in QA/QI, ongoing training, and the OMD’s specific approval of each
EMT-Paramedic participating.
NOTE: Approval to perform RSI may be rescinded by the agency OMD at any
time based solely on the judgment of the OMD. This decision will be based
upon the provider’s decision-making ability, documentation, quality assurance
reports, etc.
VIII. Regional RSI Medications
Medications approved by the ODEMSA Medical Control Committee for use in
Rapid Sequence Intubation procedures within the ODEMSA region are: etomidate,
lidocaine, succinylcholine, vecuronium and versed.
NOTE: Rocuronium will be used in a pilot program conducted by the three air
medical services in the ODEMSA region. It will not be stocked at this time in
the Regional RSI Drug Box.
A standard marked Regional RSI Drug Box (Pelican #1150) will be available at
cost to agencies whose providers are approved to perform RSI. Requests for
these drug boxes will follow the procedure listed in Section 6 of the region’s ALS
Drug Box Policies and Procedures. Regional RSI Drug Boxes must be maintained,
checked and stored in compliance with the rules and regulations of the Virginia
Board of Pharmacy and the Virginia Department of Health’s Office of Emergency
Medical Services, and the region’s ALS Drug Box Policies and Procedures.
Agencies are encouraged to use the standard Regional RSI Drug Box. Agencies
that chose to maintain their own boxes must include in those boxes all of the
medications and support items in the same concentrations and measures as listed
in the Regional RSI Drug Box Contents (see Section 4 of this document).
IX.
Regional RSI training program:
The Regional RSI training program will consist of, but will not limited to:
1. Enhanced Airway Management
a.
b.
c.
d.
e.
Airway anatomy and physiology.
Basic airway procedures.
Advanced airway procedures.
Scenario training.
Difficult airway management.
2.
Rapid Sequence Intubation Training
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Advanced anatomy and physiology.
Difficult airway predictors.
Pediatric airway problems.
Basic airway review.
Advanced airway review.
RSI procedure.
Difficult airway management.
RSI Pharmacology.
Special RSI considerations.
RSI skills training with scenarios.
Written RSI assessment.
Note: Training will include appropriate elements for pediatric RSI. At this time,
these regional Guidelines restrict RSI to patients who are over 14 years of age
and who weigh more than 45 kgs.
3. Additional Elements:
a. Practice scenarios with demonstration of adequate skill with intubation in a
variety of circumstances.
b. Written test and practical examination.
c. Patient profile discussion for successful RSI and contraindications.
d. A discussion of the circumstances as to when not to attempt RSI on a
patient (patient exclusion criteria).
e. Alternative methods to secure an airway (Combitube, oral and nasal
intubation, etc.), with emphasis on the provider defining alternative airway
management modalities for specific patients prior to the RSI attempt, and
having those modalities ready in the event of RSI failure.
f. Agency policy and regional protocol review.
g. Mandatory quality assurance/quality improvement (QA/QI.
VIII.
General Guidelines:
The following are an overview of General Policy Guidelines – see attached
regional protocols for performance of RSI.
1. Preparation
a.
Take into consideration the indications, risks and alternatives to RSI.
b.
Obtain AMPLE history.
c.
Perform a brief anatomic assessment. A thorough evaluation of the
anatomy of the hypopharynx is essential in airway management.
Perform an anatomic assessment to determine those patients who
are to be considered as RSI candidates, and those airway
alternatives that may be required with failed RSI.
d.
Perform a brief neurological assessment.
Document neurological status and GCS Score. This must precede
the administration of sedatives and paralytic agents.
d.
Essential equipment.
Suction (working with Yankauers attached)
Oxygen (connected to a BVM)
Airway (laryngoscope, ET tube, stylet, BVM – failed RSI back up
alternate airway adjuncts, Combitube and surgical cric equipment,
etc.)
Pharmacology - have all required drugs that are expected to be used
in an easily accessible and premixed condition. These agents must
be readily available upon demand when attempting RSI.
Monitoring equipment (cardiac monitor, pulse ox, ETCO2 monitor,
and BP monitor).
1)
2)
3)
4)
5)
2.
Establish an open airway and pre-oxygenate
Pre-oxygenation is required before proceeding with sedation and paralysis.
If at all possible, allow the patient to pre-oxygenate on his or her own.
Patients should be given 100 percent oxygen via non-rebreather facemask
while assembling equipment (approximately four to five (4-5) minutes), or
assist the patient’s own effort with a BVM and 100 percent oxygen for one to
two (1-2) minutes to maximize oxygen saturation.
Note: BVM assist increases potential for gastric distention with air,
which increases the possibility of vomiting and aspiration.
3. Place patient on continuous cardiac monitor, pulse
oximeter, and continuous blood pressure monitoring.
4. Verify that functioning IV line is securely in place.
5. Premedication if indicated.
Lidocaine – Use for any patient with suspected head injury to manage
increased intracranial pressure. Lidocaine has been shown to blunt the
cardiovascular response to the stimulation of the airway. Lidocaine
decreases the likelihood of tachycardia and hypertension. Lidocaine
decreases intracranial and intraocular pressure that can be associated with
RSI.
Usual Dose: 1.0 – 2.0 mg/kg IV 2-5 minutes prior to laryngoscopy
(Maximum dose 150mg. Maximum efficiency is 3-5 minutes after dosing).
Contraindications: Heart block, severe hypovolemia, bradycardia and
CHF.
Atropine (not carried in Regional RSI Drug Box) – Consider Atropine
for any patient with bradycardia prior to intubation.
Usual Dose: 0.01 mg/kg IV.
Contraindications: Third (3rd) degree heart block. Atropine may
exacerbate ischemia or induce VT or VF when used to treat bradycardia
associated with AMI.
6. Sedation
NOTE: Sedatives must be administered prior to administration of a
neuromuscular blocking agent, to eliminate the sensation of paralysis.
Etomidate: An anxiolytic sedative and hypnotic agent with an onset of
action of 30 seconds and a duration of action of from five (5) to 10 minutes.
It is well suited as an induction agent for RSI because its pharmacokinetic
profile closely matches that of succinylcholine and it has minimal
cardiovascular side effects. The transient suppression of cortisol synthesis
is of no clinical significance with a single dose.
Usual Dose: 0.3 mg/kg. Consider dose reduction in the elderly because of
age-related differences in kinetic parameters and increased risk for cardiac
depression in older hypertensive patients.
Contraindications: Adrenal insufficiency, hypersensitivity to entomidate.
Side Effects: Clinically significant adrenal dysfunction has been seen with
long-term use of etomidate.
Versed: A safe, short-acting benzodiazepine with a slightly longer duration
(30-60 minutes). Re-dosing is therefore less likely. There is also a
remarkable amnesic quality to Versed that is of great importance with the
successful completion of this skill and patient satisfaction.
Usual Dose: 2-5 mgs IV push. (based on dosing of .05mg/kg). Versed
should be administered two (2) full minutes before intubation is attempted.
Re-dosing: 2-5 mgs IV push may be repeated in 6-10 minutes after initial
dose. Additional sedation may be needed to control tube placement,
intracranial pressure and vital signs. Re-dosing may be administered to
patients who are agitated, arouseable and aware of their surroundings to
reduce the fear and stress related to the intubation.
NOTE: A significant number of patients may be intubated with the use
of sedation without paralytic agents.
NOTE: PARALYTICS ARE NOT INDICATED IF A PATIENT
MAY BE ADEQUATELY AND SAFELY INTUBATED AFTER
THE SOLE ADMINISTRATION OF VERSED.
Hypotension related to versed administration may be reversed with IV fluid
bolus.
7. Cricoid Pressure (Sellick Maneuver)
While cricoid pressure may help with visualization, the procedure is not
intended for facilitating visualization of the cords. The purpose of cricoid
pressure during intubation is to decrease the chance of regurgitation with
subsequent aspiration by pressing the cricoid cartilage firmly against the
esophagus. Cricoid pressure is applied after sedation and is not released
until after intubation, cuff inflation and verification of ET tube placement. If
pressure is released prior to inflation of the balloon, the esophagus opens
and exposes the patient to possible aspiration.
Attempting Sellick’s on a person with intact airway reflexes (i.e. not sedated
or obtunded) may precipitate coughing or vomiting. If the patient begins to
vomit, release cricoid pressure while turning patient onto side to protect the
airway from aspiration. Suction as needed. Continued cricoid pressure
during an episode of vomiting can result in iatrogenic rupture of the
esophagus.
NOTE: The Sellick Maneuver has also been reported to cause airway
obstruction because of excessive force occluding the trachea.
8.
Administration of a Neuromuscular Blocking Agent
Succinylcholine: An ultra-short-acting depolarizing –type skeletal
muscle relaxant. It is well-suited for RSI but does have some potentially lifethreatening side effects in certain patient populations. Succinylcholine has
an onset of action of 45 seconds with an initial dose. It has a duration of
action of from five (5) to 10 minutes.
Usual Dose: 1.5 mg/kg, may repeat in two (2) to three (3) minutes to
achieve paralysis (2 mg/kg in children, 3 mg/kg in infants).
Contraindications: Muscular dystrophy, myopathies, denervation
syndromes, stroke, spinal chord injury, prolonged immobilization, known
hyperkalemia.
Side Effects: Fasciculations, hyperkalemia, bradycardia, increased ICP,
Increased IOP and MH. Succinylcholine should not be given to patients for a
period of from 24 hours to 21 days after significant burns or crush injury
because of elevated potassium levels and potential for cardiac
dysrhythmias.
Vecuronium: a non-depolarizing neuromuscular blocker. It has an
intermediate duration of action of 30-60 minutes with an initial dose. It
produces clinical effects in approximately 30 seconds and intubation
paralysis in one to four (1-4) minutes.
Usual Dose: 0.1 mg/kg IVP (maximum initial dose 10mg).
Reconstitute vial with 10 ml of normal saline and shake thoroughly
Re-dosing: ½ initial dose IVP may be repeated 20 minutes after initial
dose, as indicated.
NOTE: Additional paralytics may be necessary to control tube
placement, intracranial pressure and vital signs. Hypertension and
tachycardia may be early indicators of the patients awakening to
paralysis. Patients who exhibit agitation, seizure activity, cough,
increased gag reflex or other activities which may compromise
adequate ventilation and/or airway control, need immediate
intervention.
NOTE: NEUROMUSCULAR BLOCKING AGENTS DO NOT
HAVE SEDATIVE PROPERTIES. THEY DO NOT ALTER PAIN
RECEPTION, NOR DO THEY STOP SEIZURE ACTIVITY
TAKING PLACEIN THE BRAIN!
9.
Intubation
Intubation should be performed when the muscles are fully relaxed. Do not
attempt laryngoscopy until the mandible is flaccid. If unable to intubate
the patient after the first attempt or at any time the patient’s oxygen
saturation level drops below 91%, ventilate the patient with the BVM and
100 percent oxygen for one (1) minute. If three (3) intubation attempts fail
(or sooner at the discretion of the EMT-Paramedic), ventilate the patient
with a BVM, then attempt Combitube placement. If unable to secure the
airway with the Combitube, continue ventilation of the patient with BVM
and 100 percent oxygen until satisfactory spontaneous breathing resumes,
or arrival at the receiving hospital. Consider a surgical airway if intubation
fails and ventilation is not possible.
10. Verification of tube placement
NOTE: Tube placement verification is more important than the
intubation itself. Unrecognized esophageal intubation is catastrophic
for the patient.
The position of the endotracheal tube in the trachea must be confirmed by
three (3) different methods. Acceptable documentation of tube placement
may include:
a. Presence of bilateral breath sounds and absence of breath sounds
over the epigastrium.
b. Presence of condensation on the inside of the ET tube.
c. End tidal carbon dioxide monitoring.
d. Visualization of the tube passing through the cords.
e. Esophageal detection device
NOTE: A minimum of three (3) verification methods must be
documented in the medical record.
Document patient’s oxygen saturation q five (5) minutes and CO2 by end
tidal monitoring, or other appropriate device. After each patient transfer or
movement, which may potentially dislodge the tube, the provider must reverify and document appropriate tube position.
Example: Documentation of the bedside clinical assessment, which
consists of visualizing the endotracheal tube as it passes through the vocal
cords, followed by listening over the epigastrium and listening over each
lung field for the presence and equality of breath sounds. Looking for
condensation on the endotracheal tube with exhalation, and watching for the
chest to rise and fall with inspiration. Documenting end tidal CO2,
monitoring stable or improving oxygen saturation levels and skin color, can
make further confirmation of tube placement. Routinely check tube
placement and document. Re-verify tube placement if clinical conditions
deteriorate.
11. Secure the Endotracheal Tube
Secure the endotracheal tube once it is placed and the appropriate location
of the tube has been verified. Additionally, as permitted, secure the patient’s
neck with a rigid cervical collar or other means. Use extreme caution with
any patient movement after securing the airway to prevent the tube from
becoming dislodged during the movement.
NOTE: Re-verification of appropriate tube placement is mandatory
each time after the patient is moved, and it must be appropriately
documented.
12. Considerations:
a.
b.
c.
d.
Once a neuromuscular blocking agent is given, the provider assumes
complete responsibility for maintaining an adequate airway and
ventilations.
The provider must be prepared to perform a surgical airway if
intubation cannot be executed and ventilation with a Combitube or
BVM is not possible.
The provider can maintain sedation/Paralysis per re-dosing schedule.
The provider must monitor oxygen saturations and end-tidal carbon
dioxide continuously.
13. Chemical Restraint Policy
Patients who are sedated for procedures and then maintained in a
chemically induced state of “control” following that procedure should be
managed according to the EMS agency’s restraint guidelines. Chemical
restraints are no less significant than physical restraints, and certainly pose
a greater potential risk to patients. However, the overall benefits of this
sedation/paralysis to maintain an airway certainly exceeds the potential
medication risks associated with the agents utilized for such purpose.
NOTE: Under no circumstances should RSI be used to restrain a
violent or combative patient.
14.
Documentation:
Documentation will be completed on the Prehospital Patient Care Report
(PPCR) and any agency RSI evaluation document (See Article XI and
Section 5 below).
In addition to complete documentation of patient assessment and care,
specific areas to be addressed on the PPCR will include but not be limited
to:
a. RSI indications.
b. Description of airway condition (clear, vomitus, blood, etc.).
c. Documentation of pre-oxygenation with the oxygen saturations.
d. All drugs used – doses, times and provider name administering
medications.
e. Vital signs q five (5) minutes post medication administration.
f. Number of intubation attempts (pre and post use of RSI).
g. Tube size.
h. Depth of endotracheal tube insertion and method used for securing the
endotracheal tube.
i. Three (3) methods used for tube verification. NOTE: presence of
bilateral breath sounds and no air movement over the epigastrium
are bundled as only one method of confirmation of tube position.
j. Oxygen (O2) saturation levels during procedure.
k. Documentation of neck immobilization after intubation for tube security.
l. Documentation of EKG monitor strip before and after intubation.
m. Documentation of reverification of tube placement during transport and
the methods used.
n. Status of ETT at turnover at receiving facility and after each patient
movement.
o. Physician name and signature at receiving facility.
X.
Documentation, Review and Quality Assurance:
NOTE: The ODEMSA Medical Control Committee has adopted a policy that all
incidents where Rapid Sequence Intubation is performed on a patient will be
reviewed by the agency OMD and the agency’s QA/QI committee.
Quality Assurance/Quality Improvement (QA/QI) documentation is solely for QA/QI
purposes and is not to be included in nor be considered a part of the medical record.
QA/QI documentation is confidential and not to be shared or discussed outside of
the QA process.
After the provider completes the Prehospital Patient Care Report (PPCR), the
provider will complete an agency RSI evaluation form (see Section 5). This form will
include feedback from the receiving Emergency Department physician. This
completed documentation will be submitted to the OMD or to the OMD’s designee
within 24 hours of the RSI incident.
####
OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC.
1463 Johnston-Willis Drive
Richmond, VA 23235-4730
804-560-3300  FAX: 804-560-0909
www.odemsa.vaems.org
Rapid Sequence Intubation (RSI)
Section 2
Regional Training Guidelines
Current January 2006
Enhanced Airway Management Training: Four (4) Hours
Airway Anatomy and Physiology
0.5 hour
Basic Procedures
Positioning for success
Bag-Valve-Mask technique
BLS adjuncts
Combitube
1 hour
Advanced Procedures
Oral and nasal intubation
Trauma intubation
1 hour
Scenario Training
1 hour
Difficult Airway Management
Indications for RSI
0.5 hour
Rapid Sequence Intubation Training: Nine (9) Hours
Advanced Anatomy and Physiology
Airway pathology and problems
Difficult airway predictors
Pediatric airway problems
1 hour
Basic Procedures Review
BVM competency
Combitube
0.5 hour
Advanced Procedures Review
Oral intubation competency
Nasal intubation competency
1 hour
The RSI Procedure
Patient profile
Contraindications
0.5 hour
RSI Training Guidelines
Page 2
Difficult Airway Management
Predicting problems
Techniques for the airway
Rescuing the airway
Special equipment
1 hour
RSI Pharmacology
Pre-medications
Sedation versus paralysis
Entomidate
Succinylcholine
Vecuronium
Versed
Lidocaine
2 hours
Special RSI Considerations
Trauma versus medical
Pediatric patient
Geriatric patient
Pregnant patient
Burn patient
Crush injuries
1 hour
RSI Skills Training
Integrated scenarios
Agency policy/regional protocol review
Mandatory QA/QI tool
Written RSI assessment
2 hours
Total
13 hours
Recommended Textbooks:
Manual of Emergency Airway Management by Ron Walls, M.D., Lippincott
Williams & Wilkins, 2000.
Advanced Airway Management by Charles E. Stewart, M.D., FACEP, Brady,
2002.
OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC.
1463 Johnston-Willis Drive
Richmond, VA 23235-4730
804-560-3300  FAX: 804-560-0909
www.odemsa.vaems.org
Rapid Sequence Intubation (RSI)
Section 3-A
Suggested RSI Program Elements
Current January 2006
Pending the adoption of an RSI protocol for the ODEMSA region, the
following elements should be observed in any program in the region:
1. Identify Need for RSI: This procedure is limited to EMT-Paramedics who
are cleared for RSI and it is this level of Provider who will identify the need to
perform it. NOTE: RSI in the ODEMSA region will be performed only when
there are at least two (2) ALS providers cleared for intubation on the scene,
one of whom is the RSI-cleared EMT-P (see RSI Regional Program
Guidelines).
2. Indications: RSI may be indicated in the following situations:
a. Trauma patient with the Glasgow Coma Scale (GCS) less than 9.
b. Burn patient with airway involvement, singed nares or hoarse sounds.
c. Respiratory distress patient with deterioration in the level of
consciousness and SAO2 less than 90% with interventions.
i. Asthma (high index of suspicion if history of pervious
intubation).
ii. Congestive heart failure.
d. Stroke patient with GCS of less than 9.
e. Status seizures without relief from full therapeutic (i.e., maximal
protocol recommended) doses of Valium.
f. Unconscious overdoes patient if hypoxia is not corrected with
Naloxone.
g. Hypoxia-induced combative patient in who other, less invasive O2
administration techniques (i.e. NRB 100% O2, BVM) do not reverse
the problem.
3. Contraindications: RSI is not indicated in the following situations:
a. Any patient who is less than age 14 and/or weighs less than 45 kg.
b. Any patient who has spontaneous respirations with adequate
ventilation/oxygenation and a protected airway.
c. Any patient where intubation may not be successful due to airway
obstruction or trauma (i.e. epiglottitis, major facial/laryngeal trauma with
significant edema or distortion of facial/airway anatomy).
d. Upper airway obstruction.
e. Any patient with known hypersensitivity to RSI drugs or known
hyperkalemia.
f. Any patient with penetrating eye injuries.
g. Any patient with a history of malignant hyperthermia.
h. Any patient with myasthenia gravis.
4. Prepare the Patient:
a. Pre-oxygenate by BVM and/or NRB 100% O2.
b. C-spine control as needed.
c. Place adjunct airway if possible.
d. Place patient on ECG and pulse oximeter.
e. Establish patient IV access.
5. Prepare Equipment:
a. Attach BVM to O2 source.
b. Prepare suction.
c. Check intubation kit (ETT with syringe and stylette, laryngoscope and
blade).
d. Check capnography (EasyCap and cardiac monitor).
6. Pre-medications:
a. Make sure that all required drugs that are expected to be used are easily
accessible and in premixed condition so that they are immediately
available upon demand during RSI.
b. Administer at minus-three (3) minutes:
i. Lidocaine 1.0-2.0mg/kg IV 2-5 minutes before laryngoscopy unless
contraindicated.
ii. Atropine 0.01mg/kg IV unless contraindicated.
iii. Defasiculating dose of Vecuronium 0.01mg/kg if needed.
7. Sedation: (zero point)
a. Administer Etomidate 0.3mg/kg (draw up appropriate amount from 40mg
vial) IV push.
b. Administer Versed 2.0-5.0mgs IV push (based on dosing of .05 mg/kg).
Versed should be administered two (2) full minutes before intubation is
attempted.
c. Paralytics are not indicated if a patient may be adequately and safely
intubated after the sole administration of Versed.
8.) Paralysis: (zero point)
a. Administer Succinylcholine 1-1.5mg/kg.
i. 30- to 40-second onset that lasts four (4) to six (6) minutes.
ii. Monitor for fasiculations.
b. Administer Vecuronium 0.1 mg/kg IV push (maximum initial does 10mg).
i. Produces clinical effects in approximately 30 seconds and
intubation paralysis in 1-4 minutes.
ii. Reconstitute vial with 10ml of normal saline and shake thoroughly.
iii. Re-dosing is ½ initial dose IVP 20 minutes after initial dose as
indicated.
9.)
Intubation:
c. This initially is handled by the second ALS provider. RSI-cleared EMT-P
handles medications.
d. Approximately 30 seconds after administration of the paralytic, the
patient’s muscles will relax and respirations will cease.
e. Do not attempt laryngoscopy until the mandible is flaccid.
f. RSI-cleared EMT-P applies cricoid pressure.
g. If trauma patient, maintain manual in-line c-spine stabilization.
h. Perform first intubation within one minute.
i. The position of the endotracheal tube in the trachea must be confirmed by
three (3) different methods and those three methods must be documented
in the medical record.
j. If intubation is successful, do not administer any additional sedation or
paralytics.
k. If the FIRST attempt is unsuccessful, the RSI-cleared EMT-P MUST
perform all subsequent attempts
l. If the RSI-cleared EMT-P is unsuccessful, maintain BVM with an adjunct
airway.
m. If three (3) intubations fail, place Combitube. Verify oxygenation and
ventilation as below.
n. If BVM measures fail and Combitube does not provide adequate
ventilation and oxygenation, perform immediate surgical
cricothyroidotomy.
10.) Verification:
a. Acceptable documentation of tube placement may include:
i. Presence of bilateral breath sounds and absence of breath sounds
over the epigastrium.
ii. Presence of condensation on the inside of the ET tube.
iii. End tidal CO2 monitoring on three consecutive breaths.
iv. Esophageal detection device.
v. Visualize tube passing chords.
11.) Secure Endotracheal Tube:
a. Secure endotrachael tube with holder.
b. Place C-collar to stabilize patient’s neck.
c. Use extreme caution when moving patient to prevent tube from becoming
dislodged during movement. Re-verification is mandatory after a
movement and must be documented.
12.) Long-term Paralysis and Continued Sedation:
a. Once the ETT has been verified and secured:
i. Administer Vecuronium 0.1mg/kg for paralysis.
ii. Administer ??.
iii.
Consider Morphine 4.0mg for analgesia (head injury or multiple
trauma) with BP maintaining.
1. Blood pressure> 100mmHG.
2. Repeat after 20 minutes of transport time and if BP
tolerates.
13.) Considerations:
a. Once a neuromuscular blocking agent is given, the provider assumes
complete responsibility for maintaining an adequate airway and
ventilations.
b. The provider must be prepared to perform a surgical airway if intubation
cannot be executed and ventilation with a Combitube or BVM is not
possible.
c. The provider can maintain sedation/paralysis per re-dosing schedule.
d. The provider must monitor oxygen saturations and end-tidal carbon
dioxide continuously.
e. On-line medical control always is an option.
14.) Chemical Restraint Policy:
a. Patients who are sedated for procedures and then maintained in a
chemically induced state of “control” following that procedure should be
managed according to the EMS agency’s restraint guidelines.
15.) Notification, Documentation and QA:
a. Documentation will be completed on the Prehospital Patient Care Report
(PPCR) and any agency reporting document
b. Each agency must set up a notification process that includes appropriate
agency leadership and the agency Operational medical Director (OMD) as
soon as possible by pager, phone or e-mail.
c. Each agency must establish a documentation and quality assurance
process
d. The ODEMSA Medical Control Committee has adopted a policy that all
incidents where RSI is performed on a patient will be reviewed by the
agency OMD and the agency’s QA/QI committee.
#####
OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC.
1463 Johnston-Willis Drive
Richmond, VA 23235-4730
804-560-3300  FAX: 804-560-0909
www.odemsa.vaems.org
Rapid Sequence Intubation (RSI)
Section 3-B:
Recommended Medication-Facilitated
Intubation Protocol
Current January 2006
Overview: This procedure should be used to facilitate intubations in patients 14 years
of age or older, who weight at least 45 kg, who require an invasive airway -- conscious
or semi conscious -- and who will not accept nasal or conventional oral intubation. Use
of waveform capnography is mandatory on intubated patients.
There are three levels in medication facilitated intubations. Providers may only practice
within the following levels that they have been trained and cleared to perform.
ALS Level 1 (EMT-Cardiac and EMT-Intermediates). Intubation without
medication facilitation.
ALS Level 2 (EMT-Paramedics). Medication (sedative only) assisted
intubation.
ALS Level 3 (RSI-trained EMT-Ps). Paralytic (RSI) facilitated intubation
(requires a second ALS provider)
Prehospital goal: Facilitate placement of invasive airway with use of medications.
Protocol for Management
Preparation (all levels):
1. Prepare all equipment including suction, capnography, and rescue airway.
Preoxygenate (all levels):
1. Preoxygenate with 100% oxygen.
2. BVM if needed to maintain pulse ox greater than 94%.
3. Maintain cricoid pressure.
Pretreatment (all levels):
1 For head injury patients, administer lidocaine, 01mg/kg, to decrease the rise
in intracranial pressure
Treatment :
ALS Level 1
1. Intubate patient, check ET tube placement. Secure ET tube. Attach ETCO 2
monitor.
2. Utilize difficult airway protocol if needed.
ALS Level 2 (medication facilitated)
1. Administer Etomidate, 0.3mg/kg IV for sedation. Versed 0.05mg/kg IV is an
acceptable alternative sedative (max dose 05mg).
2. Intubate patient, check ET tube placement. Secure ET tube. Attach ETCO 2
monitor.
3. Utilize difficult airway protocol if needed.
ALS Level 3 (Rapid Sequence Intubation)
1. Administer Etomidate, 0.3mg/kg IV for sedation. Versed 0.05mg/kg IV is an
acceptable alternative sedative (max dose 5mg)
2. Administer Succinylcholine 1.5 to 2.5mg/kg IV for paralysis.
3. Vecuronium 0.1mg/kg IV can be used by itself for paralysis, in patients with
contraindications to Succinylcholine, or in conjunction with Succinylcholine for
long-term paralysis.
4. Intubate patient, check ET tube placement. Secure ET tube. Attach ETCO2
monitor.
5. Utilize difficult airway protocol if needed.
Post Treatment Levels 2 and 3
1. Monitor and document airway and vitals post procedure, including continuous
waveform ETCO2 and pulse ox.
2. Versed can be given for post intubation sedation 0.05mg/kg IV
3. Vecuronium, 0.1mg/kg IV, can be given for continued paralysis if clinically
indicated. REMEMBER TO GIVE PROPER SEDATION.
4. Document procedure and waveform ETCO2.
5. Make appropriate notifications if Level 3 (RSI) is used.
Medications
Pretreatment
Sedation
ALS level 1
Lidocaine 1
mg/kg IV
none
ALS level 2
Lidocaine 1 mg/kg IV
ALS level 3
Lidocaine 1 mg/kg IV
Sedation
none
Etomidate 0.3 mg/kg
IV
Versed 0.05 mg/kg IV
Etomidate 0.3 mg/kg
IV
Versed 0.5 mg/kg
IV
Succinylcholine 1.5 to
2.5 mg/kg IV
Vecuronium 0.1
mg/kg IV
Versed 0.05 mg/kg IV
Paralytic
none
none
Paralytic
none
none
Post intubation
sedation
Post intubation
paralysis
Versed 0.05
mg/kg IV
none
Versed 0.05 mg/kg IV
none
Vecuronium 0.1
mg/kg IV
Adapted by the Old Dominion EMS Alliance
Source: Chesterfield County Fire and EMS
January 2006
OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC.
1463 Johnston-Willis Drive
Richmond, VA 23235-4730
804-560-3300  FAX: 804-560-0909
www.odemsa.vaems.org
Rapid Sequence Induction (RSI)
Section 4
Regional RSI Drug Box Contents
Current January 2006
1
1
1
2
2
2
2
2
5
1
1
each
each
each
each
each
each
each
each
each
each
each
Etomidate, 40 mg vial
Lidocaine pre-filled Syringe 2% 100mg/5ml
Succinylcholine, 200 mg vial
Versed, 1mg/ml, 5ml vial
Vecuronium, 1mg/ml, 10ml vial
0.9% Sodium Chloride INJ., USP 10ml vial
VanishPoint 5ml syringe 20g x 1” needle
VanishPoint 10 ml syringe 20g x 1” needle
Alcohol prep pads
RSI Medication Drug Dosage Card
Numbered Drug Lock seal
All boxes must be sealed with a numbered seal that is recorded by the
agency when they are filled.
Recommended container is a Pelican Box # 1150. A standard marked box
will be available at cost to agencies whose providers are approved to
perform RSI. Requests for the RSI Drug Box will follow the procedures
listed in Section 6 of the region’s ALS Drug Box Policies and Procedures.
Agencies are encouraged to use the standard Regional RSI Drug Box.
Agencies that chose to maintain their own boxes must include in those
boxes all of the medications and support items in the same concentrations
and measures as listed in the Regional RSI Drug Box Contents (see
Section 4 of this document).
Until further notice, agencies that participate in the regional RSI program
will be responsible for the costs of filling and replacing medications and
equipment in the RSI Drug Box.
Regional RSI Drug Boxes must be maintained, checked and stored in
compliance with the rules and regulations of the Virginia Board of Pharmacy
and the Virginia Department of Health’s Office of Emergency Medical
Services, and the region’s ALS Drug Box Policies and Procedures.
OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC.
1463 Johnston-Willis Drive
Richmond, VA 23235-4730
804-560-3300  FAX: 804-560-0909
www.odemsa.vaems.org
Rapid Sequence Intubation (RSI)
Section 5-A
Regional QA/QI Guidelines
Current January 2006
The ODEMSA Medical Control Committee has adopted a policy that all
incidents where RSI is performed on a patient will be reviewed by the
agency OMD and the agency’s quality assurance/quality improvement
(QA/QI) committee.
Any EMS agency that adopts rapid sequence induction is encouraged to
create a review committee and develop its own QA/QI guidelines in
coordination with the agency Operational Medical Director (OMD).
QA/QI documentation is solely for QA/QI purposes and is not to be
included in nor be considered a part of the medical record. QA/QI
documentation is confidential and not to be shared or discussed outside
of the QA/QI process.
After the ALS provider completes the Prehospital Patient Care Report
(PPCR), that provider will complete an agency RSI Evaluation Form (see
sample document next page). This form will include feedback from the
receiving Emergency Department physician.
The completed documentation will be submitted to the OMD or to the
OMD’s designee within 24 hours of the RSI incident.
####
RSI Evaluation Form
ODEMSA Region
Please print all information
Suggested for PDs 13. 14. 15 & 19
AIC: __________________________________________________
PPCR No.:______________________
EMS Agency: __________________________________________
Date of Incident__________________
Time of Call: _______________________
Patient’s Age: _______________ Gender:____________________
Pt.’s Chief Complaint: _____________________________________________
Time call dispatched:______________
Time arrived on scene:_____________
Time arrived at Pt.:________________
Time arrived at hospital:____________
Reason(s) RSI indicated:____________________________________________________________________________
Indicators for pre-medications:
None
Head Injury
Bradycardia
GCS Score prior to RSI:____________
Pre-medicated with: ___________________________ Dose: _________________________ Time: _________________
Provider administering medication_______________________________________________________
Sedative Used: _______________________________ Dose: _________________________ Time: _________________
Provider administering medication_______________________________________________________
Sedative Used: _______________________________ Dose: _________________________ Time: _________________
Provider administering medication_______________________________________________________
Paralytic Used: _______________________________ Dose: _________________________ Time: _________________
Provider administering medication_______________________________________________________
Cardiac rhythm before intubation: _________________________ Cardiac rhythm after Intubation: __________________
Time of intubation:___________ Number of attempts: _________ Size of ET tube: __________ CM to lip: ____________
02 sat. prior to intubation: _____% At any time did 02 saturation levels fall <90% during intubation process? YES
NO
Three (3) procedures used to check tube placement:
1. ___________________________________
2. ___________________________________
3. ___________________________________
Provider performing successful intubation: _________________
Was Pt. re-dosed with any RSI meds?
Pulse upon arrival at hospital?
YES
NO
Pt. transported to: ____________________________________
YES
NO
NOTE to ED Physicians: This prehospital EMS Provider attempted a special procedure on the patient
brought to your Emergency Department. Your answers to the following questions will allow the Provider’s
OMD to monitor the quality of such special procedures. Thank you.
Did the provider perform the special procedure correctly?
YES
NO
If RSI was successful, was the ET tube placement proper?
YES
NO
(Please comment below
Did you identify any complications?
YES
NO
as appropriate)
Was the procedure appropriate for this situation?
YES
NO
COMMENTS: ____________________________________________________________________________________
________________________________________________________________________________________________
Physician’s Printed Name: _________________________________ Signature: ________________________________
This RSI Evaluation Form must be attached to the completed agency copy of the PPCR form and turned
into the Agency OMD within 24 hours of the procedure.
Reviewed by: ______________________________________________, M.D. Date: ____________________________
EMS Agency: ______________________________________________
ODEMSA January 2006
OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC.
1463 Johnston-Willis Drive
Richmond, VA 23235-4730
804-560-3300  FAX: 804-560-0909
www.odemsa.vaems.org
Rapid Sequence Intubation (RSI)
Section 5-C
Glossary/Definitions
Current January 2006
Rapid Sequence Intubation – An organized sequence of induction and
paralysis used to aid and control an invasive procedure such as
intubation; the use of pharmacological agents to facilitate endotracheal
intubation.
Pediatric age – A pediatric patient’s minimum age for RSI is 14 years.
Pediatric weight – A pediatric patient must be at least 45 kgs for RSI.
EMT-Paramedic – The highest certification level in Virginia and the minimum
certification level to perform RSI in the ODEMSA region.
ODEMSA – The Old Dominion EMS Alliance, the state-designated
coordinating agency for EMS in Central Virginia’s Planning Districts 13,
14, 15 and 19.
ODEMSA Medical Control Committee – That group of physicians in Central
Virginia who set the standard of emergency care for the ODEMSA
region.
Operational Medical Director (OMD) – A physician endorsed by the regional
Medical Control Committee and the Virginia Office of EMS who provides
medical oversight and supervision to a licensed EMS agency.
Regional ALS Drug Box – The standardized, orange-colored drug box carried
on licensed EMS response vehicles which contain the medications and
related materials used by ALS providers on a day-to-day basis in the
ODEMSA region.
Regional RSI Drug Box – A special blue drug box which contains only those
special medications that are used in the RSI procedure. The Regional
RSI Drug Box only should be in the possession of an agency, or an
agency’s approved provider, endorsed by the ODEMSA Medical Control
Committee to perform RSI.
BVM – Bag-valve-mask.
Sedation – An induced state of quiet, calmness or sleep, as by means of a
sedative or hypnotic agent.
Cricoid Pressure (Sellick Maneuver) – A procedure manually performed to
decrease the chance/risk of regurgitation and subsequent aspiration
during an intubation attempt and/or when paralytic agents are
administered. The Cricoid Cartilage is depressed posteriorly to partially
block the esophagus.
Neuromuscular Blocking Agent – A chemical substance that interferes locally
with the transmission or reception of impulses from motor nerves to
skeletal muscles.
QA/QI – Process to assess the effectiveness of a medical procedure and to
indicate methods of improving the procedure to ensure a more positive
patient outcome.
Induction – The introduction of drugs that produce sedation and amnesia.
Motor endplate – The point at which nerve and muscle interact.
Acetylcholine – A chemical, released when a nerve impulse reaches the motor
endplate, that binds to receptors on the muscle cells, creating electrical
and chemical changes that result in muscular contraction.
Depolararizing agents – Paralytic agents chemically similar to acetylcholine
that bind to muscle receptor sites, cause muscle contraction, then
continue to occupy the receptor sites, preventing further contractions.
Example: succinylcholine.
Non-depolarizing agents – Paralytic agents chemically similar to acetycholine
that bind to muscle receptor sites without causing contractions, then
continue to occupy the receptor sites, preventing contractions. Example:
vecuronium.