Download Rapid Sequence Intubation

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
 Pulse oximeter
 Suction Equipment
 End-tidal CO²
 Endotracheal tubes
monitor
 Temperature probe
(LONG TERM)
 Alternative airway
equipment-laryngeal
mask airway or jet
ventilator or crich
tray
 Bag-valve-mask
device
 Glidescope
 Cardiac Monitor
Preparation
 Assign roles and responsibilities
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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 afferent
receptors 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
 Glazed eyes &
 Dissociative
nystagmus
 Watch for agitated
recovery
 *Increased BP,
HR,tonic/clonic,N/V,
hypersalivation
anesthesia
 Dose = 1-2 mg/kg
(IV)/ 4-10mg/kg IM
 Lasts approx. 30”
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
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Skeletal Muscle
Relaxer
0.1 MG/KG
IV(PARALYZING
DOSE)
Lasts 25 to 45 min.
Paralytic
 SUCCINYLCHOLINE
 Side effects:
 Neuromuscular
 Fasciculations,
blocking agent
 Dose: 1 mg/kg
 Duration: 5 min.
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?