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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.