Download Airway, Rapid Sequence Intubation

Airway, Rapid Sequence Intubation
(OPTIONAL)
Preoxygenate 100% O2
Indications for RSI
Failure to protect the airway
Unable to oxygenate
Unable to ventilate
Impending airway compromise
I
IV Procedure (preferably 2 sites)
P
Assemble Airway Equipment
Suction equipment
Alternative Airway Device
Protocols 1, 2 and 3 should be
utilized together (even if
agency is not using RSI) as
they contain very useful
information for airway
management.
Evidence of Head Injury / CVA or
Reactive Airway Disease?
YES
NO
You must be sure of
your ability to intubate
before beginning this
procedure.
Optional per local medical control
Lidocaine 1.5 mg / kg IV / IO
P
Etomidate 0.3 mg / kg IV / IO
P
Succinylcholine 1.5 mg / kg IV/ IO
or
Rocuronium 1 mg / kg IV / IO
(if Succinylcholine contraindicated)
P
P
Intubate trachea
Placement Verified
Continuous Capnography
NO
P
May Repeat
One Time
Consider Restraints Physical Procedure
Red Text
are the key
performance indicators
used to evaluate
protocol compliance.
An Airway Evaluation
Form must be
completed on every
patient who receives
Rapid Sequence
Intubation.
P
Consider Gastric Tube Procedure
Awakening or Moving after
intubation with sedative and
paralytic
NO
General Protocols
Procedure will remove
patient’s protective
airway reflexes and
ability to ventilate.
P
After 2nd cycle
YES
Versed 2 mg IV / IO
every 3 - 5 minutes as needed
P
Morphine 2 – 4 mg IV / IO
every 3 – 5 minutes as needed
Maximum 10 mg
Exit to
Failed Airway
Protocol
Consider long term paralytic
Vecuronium 10 mg IV / IO
if needed for patient movement
Notify Destination or
Contact Medical Control
Protocol 3
Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS
2012
Airway, Rapid Sequence Intubation
(OPTIONAL)
Most important caveat is determining the patient NOT APPROPRIATE for Rapid Sequence Intubation.
High Risk Patients:
Patients with the following are considered high risk: Brain illness or injury; Underlying respiratory disease; Underlying cardiac disease; Aortic disease;
Obese patients; Pregnant patients; and Patients age > 55.
All pre-hospital Rapid Sequence Intubations are to be considered HIGH RISK.
Patients with anticipated difficult airway who can be managed by basic maneuvers / BVM / CPAP with adequate oxygenation and ventilation may
require rapid transport only.
Refer to Adult Airway, and Adult Failed Airway protocols.
Specifically make sure you assess the difficulty in using a Bag Valve Mask, Laryngoscopy, BIAD, and Cricothyrotomy with each patient.
Preparation:
Assemble and test equipment. Oxygen, BVM, Suction, Laryngoscope, Gum Elastic Bougie, BIAD, Syringes, Medications, AirTraq and Cricothyrotomy
device.
Assure large bore IV with 2 sites preferable.
Pretreatment:
Administer Lidocaine with head injury, CVA, or reactive airway disease (COPD / asthma) patients. Should be given 3 minutes prior to intubation.
Evidence on true benefit is equivocal.
Paralyze and Sedate:
Give Etomidate first then paralytic in rapid succession and via rapid IV push with normal saline flushes of 10 mL.
Once medications are given DO NOT VENTILATE unless patient de-saturates below 92%: Continue high flow oxygen by mask or nasal cannula and
maintain jaw thrust to keep airway open. This is apneic oxygenation and is very effective in supplying oxygen to the blood stream even without
ventilations as long as airway patency is maintained. Maintain until intubation conditions are reached and you begin your intubation attempt. Optimal
condition should be reached in about 30 to 60 seconds.
Position:
Head extension or the Sniffing position are probably optimal. May need to elevate head / torso (pillows or stretcher) in the obese or pregnant
patient. If difficulty is anticipated use your stretcher to place the patient’s nose in line with your umbilicus.
Trauma: Utilize in-line cervical stabilization during intubation, BIAD or BVM use. During intubation or BIAD the cervical collar front should be open
or removed to facilitate translation of the mandible / mouth opening.
General Protocols
Pre-oxygenate:
Pre-oxygenation should optimally occur during initial assessment.
Provide at least 3 minutes of high flow oxygen before rapid sequence intubation.
CPAP is an effective means to provide adequate pre-oxygenation.
Place endotracheal tube into trachea:
Cricoid pressure may worsen your view and may increase risk of aspiration in some patients. Use if it improves your view.
Bimanual laryngoscopy: Use your right hand to externally manipulate the thyroid cartilage and / or head to give you the best glottic view.
Confirm placement of endotracheal tube into glottis by: Direct visualization; Chest rise and fall; Increasing oxygen saturation; End tidal CO2 device.
Maintain continuous waveform capnometry at all times to assure endotracheal tube does not become dislodged.
Post-intubation management:
Give Versed as needed to maintain sedation maintaining systolic blood pressure greater than 90.
Expect transient hypotension immediately following RSI.
Use Vecuronium only after adequate sedation if excessive patient movement is noted. Repeated doses of paralytics are discouraged.
Protect the airway with a combination of physical restraints, versed and vecuronium as needed.
Pearls
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Agencies must maintain a separate Performance Improvement Program specific to Rapid Sequence Intubation.
This protocol is only for use in patients with an Age 12 or greater or patients longer than the Broselow-Luten Tape.
Once a patient has been given a paralytic drug, YOU ARE RESPONSIBLE FOR VENTILATIONS if desaturation occurs.
Continuous Waveform Capnography and Pulse Oximetry and are required for intubation verification and ongoing patient monitoring
Before administering any paralytic drug, screen for contraindications with a thorough neurologic exam.
If First intubation attempt fails, make an adjustment and try again:
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Different laryngoscope blade ●
Change head positioning
Different ETT size
●
Continuous pulse oximetry should be utilized in all patients.
Change cricoid pressure
●
Consider applying BURP maneuver (Back [posterior], Up, and to pt’s Right Pressure)
This procedure requires at least 2 EMT-Paramedics. Divide the workload – ventilate, suction, cricoid pressure, drugs, intubation.
Protect the patient from self extubation when the drugs wear off. Longer acting paralytics may be needed post-intubation.
Consider Naso or orogastric tube placement in all intubated patients to limit aspiration and decompress stomach if needed.
Protocol 3
Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS
2012