RSI - Adult Flashcards
How should the head be elevated before RSI?
20-40 degrees if able - ear to sternal notch
When is RSI indicated?
Failure to maintain airway
Failure to oxygenate
Failure to ventilate
Anticipated negative clinical course
Safety - for patient or crew
What piece of equipment should NOT be used to pre-oxygenate a patient prior to RSI?
ETCO2 NC
How long should a patient be pre-oxygenated before intubation attempt in RSI?
3 mins
How should a patient be pre-oxygenated prior to RSI?
O2 via NRB at or above 25lpm
or
PPV at 100% O2
or
O2 apneic oxygenation with NC
What acronym is used for RSI assessment?
HEAVEN
What does HEAVEN stand for?
Hypoxemia
Extremes of sizes
Anatomic abnormalities
Vomit/Blood/Fluids
Exsanguination
Neck mobility
What technique can be utilized for the presence of secretions in the airway?
SALAD technique
What does SALAD stand for?
Suction-Assisted Laryngoscopy Airway Decontamination
What medication can a critical care medic administer pre-RSI for hypotension?
Epinephrine 2-10mcg
What should be done with a c-collar prior to RSI?
It should be removed.
When should a patient be RSI’d?
If they are hemodynamically stable and cannot control or maintain their own airway secondary to ventilation and oxygenation issues.
When should a patient NOT be RSI’d?
Apnea, respiratory arrest, loss of landmarks, FBAO, uncorrected hypoxia, inability to ventilate with BVM, secretions in airway, MAP < 65 without resuscitation
CAUTION in significant facial or airway trauma, consider cricothyrotomy
What are the three components of hemodynamic stability?
MAP > 65
Adequate tissue perfusion
Absence of hypoxia
What are the three components of hemodynamic instability?
Map < 65
Inadequate tissue perfusion
Presence of hypoxia despite intervention
What should be considered for a hemodynamically unstable patient prior to RSI?
Fluid resuscitation
What is the dose for fluid resuscitation prior to RSI?
20ml/kg NS or Normo-sol IV bolus
If a patient presents as hemodynamically unstable, should they immediately be RSI’d?
No - fluid resuscitation should be performed first.
If MAP > 65, what sedatives can be used for RSI?
Ketamine: 1-2mg/kg rapid IVP
or
Versed: 5-10mg rapid IVP
What is another name for Versed?
Midazolam
What is the RSI dose of Ketamine?
1-2mg/kg rapid IVP
What is the RSI dose for Versed?
5-10mg rapid IVP
If MAP > 65, what paralytics can be used for RSI?
Rocuronium: 1mg/kg IVP
or
Etomidate: 20mg IVP (repeat ONLY once)
What is the RSI dose of Rocuronium?
1mg/kg IVP
What is the RSI dose of Etomidate?
20mg IVP (repeat ONLY once)
What is another name for etomidate?
Amidate
How many times may etomidate be repeat dosed?
Repeat ONLY once
What are some methods to confirm successful airway capture?
Continuous waveform capnography, bilateral chest rise and fall, color improvement, bilateral breath sounds upon auscultation, condensation in tube
In what order should RSI meds be given?
Sedation first, paralytic second
If able, what should be done after successful intubation?
Insertion of NGT/OGT
What type of medication should be routinely administered post-successful RSI?
Pain medication / analgesic
What are the medications used for post-intubation pain management?
Fentanyl: 0.5-1mcg/kg IV, max dose of 100mcg. May repeat every 5min
or
Dilaudid: 0.5-1mg, max single dose 1mg. Max TOTAL dose 3mg
or
Ketamine: 0.5-1mg/kg IV, may repeat every 10min PRN
or
Versed: 2.5-5mg IV, may repeat in 3-5 min. Consider lower dose in age > 65yrs or chronically ill. Max TOTAL dose 20mg
What is the post-intubation pain medication dose for Fentanyl?
0.5-1mcg/kg IV, max dose of 100mcg single dose. May repeat every 5min
What is the post-intubation pain medication dose for Dilaudid?
0.5-1mg, max single dose 1mg. Max TOTAL dose 3mg
What is the post-intubation pain medication dose for Ketamine?
0.5-1mg/kg IV, may repeat every 10min PRN
What is the post-intubation pain medication dose for Versed?
2.5-5mg IV, may repeat in 3-5 min. Consider lower dose in age > 65yrs or chronically ill. Max TOTAL dose 20mg
How often can the post-intubation pain management dose of Fentanyl be administered?
Every 5mins
What is the max single dose of post-intubation pain management Fentanyl?
100mcg
What is the max single dose of post-intubation pain management Dilaudid?
1mg
What is the max TOTAL dose of post-intubation pain management Dilaudid?
3mg
How often can the post-intubation pain management dose of Ketamine be administered?
May repeat every 10min PRN
When can the post-intubation pain management dose of Versed be repeated?
May repeat in 3-5 min
What should be considered when administering the post-intubation pain management dose of Versed be repeated?
Consider lower dose in age > 65yrs or chronically ill
What is the total max dose of the post-intubation pain management dose of Versed?
Max TOTAL dose of 20mg
If patient is refractory to fluid resuscitation, what should be considered?
IV push dose pressors and/or vasopressin infusion: Phenylephrine or epinephrine
What medications can a critical care medic administer if a patient is refractory to fluid resuscitation?
///CRITICAL CARE ONLY///
Phenylephrine: 10mg mixed in 100ml (100cg/ml) 50-200mcg every 2-5min IVP
or
Epinephrine (1:1,000): 2mg mixed in 250ml. 5-10mcg every 2-5min IVP
or
Epinephrine (1:10,000 - CARDIAC EPI): 1mg into 9mL NS flush (10mcg/ml). 5-10mcg every 2-5 min IVP
What can a non-critical care medic administer if a patient is refractory to fluid resuscitation?
Phenylephrine: 10mg mixed in 100ml NS (100mcg/ml). 50-200mcg/min
or
Epinephrine (1:1,000): 2mg mixed in 250ml (8mcg/ml). 2-10mcg/min, titrate at 1mcg/min at 2min intervals
What is the critical care medic dosage of Phenylephrine for a patient refractory to fluid resuscitation?
///CRITICAL CARE ONLY///
Phenylephrine: 10mg mixed in 100ml (100cg/ml) 50-200mcg every 2-5min IVP
What is the critical care medic dosage of Epinephrine 1:1,000 for a patient refractory to fluid resuscitation?
///CRITICAL CARE ONLY///
Epinephrine (1:1,000): 2mg mixed in 250ml. 5-10mcg every 2-5min IVP
What is the critical care medic dosage of Epinephrine 1:10,000 (CARDIAC EPI) for a patient refractory to fluid resuscitation?
///CRITICAL CARE ONLY///
Epinephrine (1:10,000 - CARDIAC EPI): 1mg into 9mL NS flush (10mcg/ml). 5-10mcg every 2-5 min IVP
What is the non-critical care medic dosage of Phenylephrine for a patient refractory to fluid resuscitation?
Phenylephrine: 10mg mixed in 100ml NS (100mcg/ml). 50-200mcg/min
What is the non-critical care medic dosage of Epinephrine (1:1,000) for a patient refractory to fluid resuscitation?
Epinephrine (1:1,000): 2mg mixed in 250ml (8mcg/ml). 2-10mcg/min, titrate at 1mcg/min at 2min intervals
