RSI Flashcards
When to paralyze?
Can I ventilate?
Can I oxygenate?
MUST be able to answer yes to BOTH before paralyzing.
Indications for RSI
- Can pt follow commands, respond accordingly?
- Can pt control their own secretions?
- What clinical course do you anticipate?
Monitoring
Pulse oximetry - SpO2
<93% mild hypoxia
85-90% moderate hypoxia
<85% severe hypoxia
Capnography - EtCO2
Quantitative
Waveform
Respiratory Failure
Simplistic: PaCO2 > 50mmHg
EtCO2 always lower than PaCO2
SO…ETCO2 > 50 = respiratory failure.
Actual definition:
PaO2 < 60 mmHg
PaCO2 > 50 mmHg
Best place for O2 probe
Forehead, lip, cheek
Finger can give significantly delayed readings because in shock, blood is shunted to the core.
8 P’s of RSI
- Preparation (ie HEAVEN, pre-oxygenate)
- Positioning (head @ 30 degrees, earlobes in line with xyphoid. Towel under neck).
- Passive oxygenation (NC@15 +NRB@15 vs BVM for spontaneously breathing pts)
- Premedication (blunt physio response)
- Paralysis (and induction)
- Protection (positioning)
- Placement (with proof - EtCO2)
- Post-intubation management
HEAVEN Criteria
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
DL intubation
Direct laryngoscopy
VL intubation
Video Laryngoscopy
Grade 2 view preferred because camera sits about 1/2 inch back from tip of blade.
BVM use
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.
Atropine
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
Fentanyl
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
Push dose pressors
Epinephrine
Phenylephrine
Epinephrine
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
Phenylephrine
Start with 100mL NS
Add 1mL phenylephrine
Equals 100mcg/mL
Dosing: 50-200 mcg every 1-5 minutes
Shock Index
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
Ketamine
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
Etomidate
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
Paralyzing agents
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
Succinylcholine
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
Rocuronium
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
Vecuronium
Dose: 0.1mg/kg
Route: IV/IO
Onset: 2 min
Duration: 45-60 minutes
Indications: long-term paralysis
Contraindications: allergy, unsecured airway
non depolarizing
ETT Sizing
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
ETT Confirmation
Visualization
EtCO2 capnography is the gold standard
Bilateral breath sounds
Assess epigastric sounds
Post-intubation
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
