PHEA

Question 1

Indications for RSI

Answer 1

Risk-benefit decision in every case - Unstable upper airway injury (e.g. fractured thyroid cartilage) would ideally wait for awake fibre optic but need backup plan

1. Actual or impending airway compromise
2. Ventilatory failure
3. Unconsciousness
4. Patients who are unmanageable or severely agitated after head injury
5. Anticipated clinical course - the patient is anticipated to deteriorate en route to the hospital and therefore potentially safer to carry out RSI at an earlier stage
6. Humanitarian need

Question 2

Pre-ox

Answer 2

3 minutes with BVM (tight seal)

Aim to remove nitrogen and maximise O2 reservoir

Question 3

Standard trauma induction

Answer 3

Standard -
Fentanyl 3mcg/kg + ketamine 2mg/kg + roc 2mg/kg
Max roc 200mg (IBW 100kg)

Severe hypovolaemia & elderly 1-1-2

Critically unstable/peri-arrest (GCS 3) - omit Fentanyl and/or ketamine

Question 4

Asthma

Answer 4

Ketamine 2mg/kg + roc 2mg/kg

Question 5

Status epilepticus

Answer 5

Thiopentine 2-4mg/kg + roc 2mg/kg
Reduce thio if concerned about CVS status and/or acidaemia

OR

Propofol 
1mo - 15 yrs 3mg/kg
16 yrs - 54 yrs 2mg/kg
55+ yrs or severely debilitated 1mg/kg
Seizure suppression less than thio - need midazolam or Propofol infusion

If seizures due to other cause, e.g. Sepis then consider alternative agent

Question 6

Anticipated difficult intubation

Answer 6

Ketamine 2mg/kg + roc 2mg/kg

Sux is out

Question 7

Medical neuro e.g. SAH

Answer 7

Consultant call

If no time to call, remember 3-2-2 is default

Question 8

Post RSI sedation

Answer 8

Evaluate clinical picture including physiology and anaesthetic needs. Use drugs for specific needs and in “considered doses”
Analgesia - fentanyl
Sedation - midazolam or ketamine
NMB - roc

Question 9

Post RSI hypotension

Answer 9

Consider/address obstructive and hypovolaemia shock prior to concluding hypotension is due to anaesthetic agents
Strongly consider volume resuscitation prior to RSI
Adrenaline (push dose) and metaraminol as needed if excluded other causes
Pre drawn pressors for medical, not standard for traums

Question 10

Pre RSI

Answer 10

Consider volume resuscitation if think might be hypovolaemic

Scene safety
Communicate - risk assessment, plan including drug regimen and brief
Sedation to facilitate pre-oxygenation - midazolam 1-2mg (less if hypovolaemic/tensive). Non head injured 20-30mg ketamine
Location - 360 (even if near/actual cardiac arrest), outside ambulance unless severe bad weather
If rendezvous at hospital, consider in Resus but need to agree and brief local team
Monitoring - AAGBI standard on tempus (backup nonin SpO2 and EMMA EtCO2)
Pre-oxygenate - consider NPA & OPA, HF until checklist then BVM +/- gentle ventilation. Consider apneoic O2 in bariatric or predicted airway difficulties
Positioning - ear to sternal notch, ramp obese

Kit
Vascular access x2 with long line
2 x O2
2 x Suction 
MAC 4 blade (>12yrs)
Standard kit dump

People
Cricoid routine but can be omitted if felt to compromise care
Brief including difference between Cricoid and ELM
C-spine

Checklist
Complete quiet and stop traffic

Question 11

Post RSI oxygenation

Answer 11

Titrate O2 to SaO2 94-98%
Default peep 5cm
Lung protective ventilation - tidal volume 6-8ml/kg

Question 12

Confirm tube

Answer 12

See tube passing through cords
Equal chest rise
Auscultation of breath sounds
Absence of epigastric sounds with respiration
***EtCO2 with box waveform***

Question 13

Failed intubation

Answer 13

iGel 1st line
If nil to optimise, ventilating well and potentially tricky surgical airway -> leave on iGel
V v occasionally allow to spont breath on iGel
Most should be rescued with surgical airway