Ch 20: Rapid Sequence Intubation Flashcards
What is Rapid Sequence Intubation
Administration of:
- A Potent Induction Agent THEN
- A Neuromuscular Blocking Agent (NMBA)
To induce:
- Unconsciousness AND
- Motor paralysis.
Avoids use of Bag Valve Mask, gastric distention and aspiration.
No cricoid pressure as it impairs visualization and does not prevent aspiration.
4 Steps BEFORE Rapid Sequence Intubation (RSI)
- Assess for a difficult airway.
- Prepare equipment, medications and backup plans.
- Preoxygenate for at least 3 minutes.
- Optimize hemodynamics to avoid crash.
Indications AND Contraindications
of
Rapid Sequence Intubation
- Difficult Airway.
- Contraindication to succinylcholine THEN use Rocuronium.
7 Ps of Rapid Sequence Intubation
Preparation
Preoxygenation
Preintubation Hemodynamic Optimization
Paralysis after Induction
Positioning
Placement with Proof
Postintubation management
RSI Preparation
- Assess airway difficulty
- Backup plan and staff
- Monitor Saturation, BP, EKG and waveform capnography.
- 2 Good IVs
- Medications labeled
- Video laryngoscope at bedside and tested.
- Manual laryngoscope tested.
- ETT prepared and cuff tested. If difficulty expected have 0.5 smaller ready.
- Stylet and bougie
Why preoxygenate?
- Allow several minutes of optimal oxygenation during apnea.
- Healthy 70kg adult 8 minutes to desat.
- Obese adult 2.5 minutes.
- More important 90 to 0% saturation occurs in 45s (small children) to 120s (Healthy adult)
- Oxygen stored in tissue, blood and functional residual capacity.
- Fill up on 100% oxygen generally at 3 minutes or 8 vital capacity breaths.
- Run NC at 5 to 15L while apneic.
- Preoxygenate obese patients while sitting upright.
-
Most patients WILL NOT recover spontaneous breathing before catastrophic hypoxia!!
* HFNC may be better than NRB mask*
Preintubation hemodynamic optimization strategies
- Identifying and mitigating cardiopulmonary vulnerabilities
- Increased ICP, Ao dissection, ICH, cardiac isch.—>Fentanyl to blunt sympathetic response
- Hypotension: bleeding, dry, sepsis, PE—>Fluids and/or blood.
- Refractory hypotension—>Epi or Neo-Synephrine
- Refractory hypoxia—>BiPap or CPAP
- Tension PTX—>Chest tube
Induction agents can cause vasodilation and cardiac depression
Intubation can induce hypertensive response
Paralysis after induction
- Induction agent given IVP
- NMBA-Succinylcholine (Sux) or Rocuronium (Rock)
Do not bag. INTUBATE
Positioning after RSI
- Brought to the end of the bed
- Head elevated and extended if no C spine trauma suspected.
- Keep 15L NC going.
- Might have to bag pt. w iffy saturations prior to RSI
Placement of ETT with proof
- 45 seconds after Sux or 60 seconds after Rock check for flaccid jaw
- Intubate
- ETCo2 detector at least. ET quantitative capnography best.
Postintubation management
- Secure tube
- Begin mechanical ventilation
- Assess BP. If low consider
a) Tension PTX: difficult bagging, High PIP, quiet breath sounds —>Chest tube
b) Poor venous return: Pt. with high PIP/inc IThor pressure—>bolus, inc E time, dec sedative
c) Induction agent—>Bolus and reduce sedation
d) Cardiogenic: History, EKG—>Bolus, pressors, reduce sedation
RASS-Richmond Agitation Sedation Scale
+4 Combative and violent
+3 Very Agitated-Pulling and aggressive
+2 Agitated-Fights ventilator and frequent movement
+1 Restless-but not aggressive or vigorous
0 Alert and calm
- 1 Drowsy-Can stay awake 10s
- 2 Light sedation-Briefly awakens to voice
- 3 Moderate sedation-movement or eye opening to voice
- 4 Deep sedation-Won’t respond to voice. Responds to shaking
- 5 Unarousable.
Methods for long term sedation
1) Propofol: 0.5 to 1mg bolus. 25 to 50 ug/kg/minute. Titrated.
2) Midazolam (versed) 0.1 to 0.2 mg/kg WITH analgesia Fentanyl 2ug/kg or dilaudid 0.03mg/kg
3) If paralysis required Vecuronium 0.1mg/kg. MUST continue sedation/analgesia.
RSI Success and Complications
1) 85% first attempt success. 99.4% ultimate success rate.
2) Event rate 12%: Esophageal intubation 3.3%. Hypotension 1.6%
RSI vs Sedation alone:
85% first attempt success vs 76% w sedation alone. NEAR III study
DELAYED Sequence Intubation
1) Pt. difficult to oxygenate or combative.
2) Ketamine 1mg/kg IV
3) 3 minutes NRB mask or Bipap or CPAP.
4) When fully oxygenated PUSH NMBA and Intubate
