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ODEMSA Regional
RSI Guidelines-2005
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 EMTParamedic 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.
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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 with head injuries requiring support of ventilation and/or oxygenation.
6. Combative patients with compromised airways.
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.
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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.
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5. An 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.
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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.
f.
Practice scenarios with demonstration of adequate skill with intubation in a
variety of circumstances.
Written test and practical examination.
Patient profile discussion for successful RSI and contraindications.
A discussion of the circumstances as to when not to attempt RSI on a
patient (patient exclusion criteria).
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.
Agency policy and regional protocol review.
g.
Mandatory quality assurance/quality improvement (QA/QI.
b.
c.
d.
e.
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
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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.
e.
Essential equipment.
1) Suction (working with Yankauers attached)
2) Oxygen (connected to a BVM)
3) Airway (laryngoscope, ET tube, stylet, BVM – failed RSI back up
alternate airway adjuncts, Combitube and surgical cric equipment,
etc.)
4) 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.
5) Monitoring equipment (cardiac monitor, pulse ox, ETCO2 monitor, and
BP monitor).
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.
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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 agerelated 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 longterm use of etomidate.
Versed: A safe, short-acting benzodiazepine with a slightly longer duration (3060 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.
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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 life-threatening
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.
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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 CO 2 by end tidal
monitoring, or other appropriate device. After each patient transfer or movement,
which may potentially dislodge the tube, the provider must re-verify and
document appropriate tube position.
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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.
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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.
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