RSI

Question 1

When to paralyze?

Answer 1

Can I ventilate?
Can I oxygenate?

MUST be able to answer yes to BOTH before paralyzing.

Question 2

Indications for RSI

Answer 2

1. Can pt follow commands, respond accordingly?
2. Can pt control their own secretions?
3. What clinical course do you anticipate?

Question 3

Monitoring

Answer 3

Pulse oximetry - SpO2
<93% mild hypoxia
85-90% moderate hypoxia
<85% severe hypoxia

Capnography - EtCO2
Quantitative
Waveform

Question 4

Respiratory Failure

Answer 4

Simplistic: PaCO2 > 50mmHg
EtCO2 always lower than PaCO2
SO…ETCO2 > 50 = respiratory failure.

Actual definition:
PaO2 < 60 mmHg
PaCO2 > 50 mmHg

Question 5

Best place for O2 probe

Answer 5

Forehead, lip, cheek
Finger can give significantly delayed readings because in shock, blood is shunted to the core.

Question 6

8 P’s of RSI

Answer 6

1. Preparation (ie HEAVEN, pre-oxygenate)
2. Positioning (head @ 30 degrees, earlobes in line with xyphoid. Towel under neck).
3. Passive oxygenation (NC@15 +NRB@15 vs BVM for spontaneously breathing pts)
4. Premedication (blunt physio response)
5. Paralysis (and induction)
6. Protection (positioning)
7. Placement (with proof - EtCO2)
8. Post-intubation management

Question 7

HEAVEN Criteria

Answer 7

H Hypoximia - DL
E Extremes of size - VL
A Anatomic disruption/obstruction - VL
V Vomit/blood/fluid in airway - DL/VL
E Exsanguination - DL
N Neck mobility - VL

Question 8

DL intubation

Answer 8

Direct laryngoscopy

Question 9

VL intubation

Answer 9

Video Laryngoscopy
Grade 2 view preferred because camera sits about 1/2 inch back from tip of blade.

Question 10

BVM use

Answer 10

SpO2 > 93%
PEEP
EtCO2 between BVM and mask
Bag every 6-8 sec
Bag slowly - inflation time of 2-3 sec
Adult BVMs can provide too much tidal vol.

Question 11

Atropine

Answer 11

Dose: 0.02 mg/kg
Route: IV/IO
Onset: 2-4 min
Duration: varies
Indications: prevention and tx of bradycardia in pediatric patients <1yo w/use of succinylcholine and the tx of bradycardia in adult pts during RSI
Contraindications: allergy

Question 12

Fentanyl

Answer 12

Dose: 1-3 mcg/kg
Route: IV/IO
Onset: 1-3 min
Duration: 15-20 minutes
Indications: blunting of circulatory response to intubation or suspected/known increased ICP or cardiovascular disease
Contraindications: allergy, caution w/documented hx of rigid chest syndrome

Question 13

Push dose pressors

Answer 13

Epinephrine
Phenylephrine

Question 14

Epinephrine

Answer 14

Start with 10mL saline flush
Expel 1mL
Add 1mL epi 1:10,000
…For a concentration of 10mcg/mL

Dosing: 5-20mcg every 1-5 minutes

Question 15

Phenylephrine

Answer 15

Start with 100mL NS
Add 1mL phenylephrine
Equals 100mcg/mL

Dosing: 50-200 mcg every 1-5 minutes

Question 16

Shock Index

Answer 16

pulse rate / systolic BP
HR 120, BP 66/37 –>120/66 = 1.8

Shock index >0.9 = high mortality potential

HR 100, SBP 100 = shock index of 1.0

Question 17

Ketamine

Answer 17

In high shock index patients, more risk for blunted hypertensive responses and more frequent hypotension.

Dose: 1-2 mg/kg RSI induction
Dose: 4mg/kg IM excited delirium
Dose: 0.1-0.25 mg/kg pain management
*Shock index >0.9, reduce by 50%
Route: IV/IO
Onset: variable
Duration: variable
Indications: sedation for induction with severe bronchospasm; RSI; excited delirium; pain management.
Pearls: Can cause hypersalivation in kids.
Pearls: Push slowly over 2 minutes
Contraindications: allergy, hypertension

Question 18

Etomidate

Answer 18

Dose: 0.3 mg/kg
Route: IV/IO
Onset: 15-45 seconds
Duration: 3-12 minutes
Indications: sedation for induction / neurological protection
Contraindications: allergy, adrEnal insufficiency, be cautious in hypertension

Question 19

Paralyzing agents

Answer 19

depolarizing vs polarizing

Depolarizing:
Non-competitive
Binds with acetylcholine at neuromuscular junction, causing sustained depolarization of the muscle cell (burns through O2)
Succinylcholine

Polarizing:
Competitive
Binds with acetylcholine in a competitive, non-stimulatory manner; no receptor depolarization.
Caution with myasthenia graves, Duchenne’s, MS, ALS
Rocuronium, vecuronium

Question 20

Succinylcholine

Answer 20

Dose: 1.5-2.0 mg/kg
Route: IV/IO
Onset: 30-60 seconds
Duration: 4-10 minutes
Indications: paralysis for induction
Contraindications:
Allergy
known or suspected hyperkalemia
hx malignant hyperthermia
burns/crush injuries within 24hr
spinal cord injury/stroke >5 days-6mo
neuromuscular disease
myopathy
Desaturation occurs more quickly than with other drugs

Question 21

Rocuronium

Answer 21

Generally preferred over Etomidate
Dose: 0.6-1.2 mg/kg
Route: IV/IO
Onset: 55-70 seconds
Duration: 30-60 minutes
Indications: paralysis for induction/continual
Contraindications: allergy
non depolarizing

Question 22

Vecuronium

Answer 22

Dose: 0.1mg/kg
Route: IV/IO
Onset: 2 min
Duration: 45-60 minutes
Indications: long-term paralysis
Contraindications: allergy, unsecured airway
non depolarizing

Question 23

ETT Sizing

Answer 23

Women: 7.0-8.0
Men: 8.0-9.0
Pediatrics >1yr:
weight-based guide
(age+16)/4
For neonates, move decimal…
…ie 40 week baby = 4.0 tube
…ie 35 week baby = 3.5 tube

Question 24

ETT Confirmation

Answer 24

Visualization
EtCO2 capnography is the gold standard
Bilateral breath sounds
Assess epigastric sounds

Question 25

Post-intubation

Answer 25

Secure ETT via commercial device Place all pts on na transport ventilator Continue pain management with fentanyl/ketamine Continue sedation; ketamine/versed/valium Consider continued paralysis