Download Rapid Sequence Intubation

Intro to:
Objectives
Define RSI
 Identify the Indicators for using RSI
 Identify the relative contraindications and
disadvantages of RSI
 Discuss the different roles in the RSI process
 Review the crucial 7 P’s of RSI
 Review the medications used during RSI
 Review a difficult airway and identify
alternative tools and techniques

What is RSI?
Why RSI?
Respiratory failure
 Inability to protect own airway
 Impending or potential airway
compromise
 GCS less than 8
 Intractable seizures

Relative contraindications to RSI
Airway obstruction
 Distorted anatomy
 Major facial or laryngeal trauma
 Angioedema

Disadvantages of RSI
Hypoxia if unable to complete intubation
 RSI blocks the patient’s involuntary
reflexes and muscle tone in the
oropharynx and larynx
 Adverse medication reactions
 Masks underlying symptoms
 Requires considerable amount of
training and recurrent training

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The benefit of obtaining airway control
must always be weighed against the risk
of complications in these patients.

You are taking a breathing patient and
making them APNEIC
RSI Equipment
Airway equipment (ET, syringe, stylette,
etc)
 Oxygen
 Suction equipment
 Ecg monitor
 IV equipment
 SaO2 monitor
 Capnography
 RSI meds

It’s a team effort!
Skilled intubator
 Timekeeper/scribe
 Vital sign monitor
 Medication administrator
 Assistant

Before you get started…. In the
ideal world
Get medical history
 Obtain baseline neuro exam
 Check all your equipment
 Confirm pt. weight

7 Essential P’s of RSI
Preparation
 Pre-oxygenate
 Pre-medicate
 Paralysis and Induction
 Protection
 Placement of the tube
 Post Intubation management

Preparation

Prepare all equipment
including ETT, suction,
pulse oximeter, IV and
monitor

Position patient in sniff
position if C-spine
immobilization is not
indicated.
Pre-Oxygenate
Pre-oxygenate with 100% oxygen via
NRB for at least 3 min. or 8 vital
capacity breaths with 100% oxygen.
 If ventilatory assistance is necessary
with BVM, be gentle and apply cricoid
pressure.

Do you predict a difficult airway?
Short neck or no neck
 Small mandible
 Obesity
 Facial/maxillary trauma
 Edema or infection
 Degenerative spinal disease

What does a difficult airway
mean to you?

Be prepared!

Have plan B, C, and D if intubation fails.
Tools for a difficult airway
Have one ETT tube size smaller &
bigger available
 ETTI (Bougie, Eshman, etc)
 Back up devices (Combitube, King
airway)
 Surgical airway kit

Are you ready?
What drugs do we use?

Oxygen
 Ventilate while preparing for RSI
Lidocaine?
 Atropine?
 Versed
 Etomidate
 Succinylcholine
 Vecuronium

Procedure
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Pre-oxygenate – (NOT hyperventilate) for 2 – 3
min.
Assemble equipment
Proximal IV preferred
Connect pt. To monitor
Lidocaine (TBI)
Atropine (children < 10)
Versed
Etomidate
Succinylcholine
Sellick maneuver
Procedure, cont.

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Stop ventilations
Observe for fasiculations
Intubate
 If unable to ventilate in 20 sec. , stop and ventilate for
30 – 60 sec.
 May give second dose of Sux (1 – 1.5 time initial dose
 If bradycardia occurs, give Atropine and
hyperventilate

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Confirm intubation
Attach Easy Cap or capnography device
Administer Vecuronium
MONITOR PATIENT
Protect the Patient
Maintain cervical stabilization prn
 Maintain cricoid pressure until tube
placement is confirmed and secured.
 Constant vigilance of monitoring
oxygenation

Whose tube is it?
The most experienced medic!
 If unable to intubate within 20 seconds
or SaO2 drops below 92%, STOP and
ventilate with BVM
 Confirm placement
 Release cricoid pressure

How did you confirm the tube?
Gold standard (visualized tube passing
through the cords
 Capnography
 Mist in the tube
 Bilateral breath sounds

Recheck tube placement after every patient
move, if airway resistance occurs or
increases, hear rate decreases, or O2
desaturation occurs
Post medication
Continue paralysis with Vecuronium
 Continue sedation with Versed
 Consider pain control

What if you can’t get the tube
in??
Provide 100% oxygen with BVM
 Consider back up device
 Consider surgical airway

All neuromuscular Blocking
Agents:
Work by blocking the natural
transmission of nerve impulses to
skeletal muscles.
 No direct effect on Heart, Digestive
system, Brain, Pupillary response,
Smooth Muscle or other organ systems
 No effect on mentation or pain
perception!
 No direct effect on seizure activity.

Remember….

If performed correctly, RSI will take
between 7 – 10 minutes.

You are taking a breathing patient and
making them apneic.

Always be prepared and know your RSI
protocol.