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Rapid Sequence

Intubation

In the Emergency Department

Rapid Sequence Intubation

 RSI
 The use of medication to facilitate passing the
endotracheal tube
 Analgesics
 Sedatives
 Paralytics
 CONTROLLED procedure
 Will take several minutes to accomplish
 Requires a team effort
 The ultimate goal is to secure an airway
without having the patient vomit and aspirate.

Indications for RSI  Impending airway obstruction  Facial fractures…no excessive oral bleeding  Facial burns…inhalation injury  Expanding retropharyngeal hematoma  Excessive work of breathing  Example…the exhausted asthmatic  Shock  GCS <8  Persistent hypoxia (<90%) .

6 P's of RSI  Preparation  Preoxygenation  Pretreatment  Paralysis (with induction)  Placement of the tube  Post intubation management .

Preparation  Oxygen Source  Pulse oximeter  Suction Equipment  End-tidal CO²  Endotracheal tubes monitor  Bag-valve-mask  Temperature probe device (LONG TERM)  Glidescope  Alternative airway  Cardiac Monitor equipment-laryngeal mask airway or jet ventilator or crich tray .

Preparation  Assign roles and responsibilities  Leader  Intubationist  Cricoid pressure  Monitoring  Medications  Documentation .

2. Preoxygenate  3-5 minutes with 100% O2 bag mask to ensure adequate oxygen reservoir in lungs during apnea  Assure age appropriate fitting mask .

 Reflexes can cause: – Increased intracranial pressure (ICP) – Stimulation of upper & lower respiratory tract increasing airway resistance.3. – Stimulation of autonomic nervous system. with increase heart rate and BP (vagal stimulation cause decrease in pediatric!) . hypopharynx and larynx. Pre-treatment  Laryngoscopy causes stimulation of afferent receptors in the posterior pharynx.

Pre-treatment  Attenuate (weaken) normal physiologic & pathophysiological reflex responses caused by airway manipulation during laryngoscope and insertion of an endotracheal tube.Defasiculating agent .Lidocaine .Atropine . .

and in young children.Pre-treatment meds  Atropine – Treats brady response to SUX.  Lidocaine – Helps decrease ICP associated with intubation.  Vecuronium (defasiculationg dose)- keeps muscles from fasiculating (twitching) when using “Succs” .

Paralysis (with induction)  Check patency of line first!  Make sure everyone is ready  Give IV pushes rapidly and flush  Anesthesia before paralysis!  *Induction agent is followed immediately by the paralytic without waiting to see if ventilation can be maintained  Hallmark of RSI .4.

3 mg/kg  Induction time= 5-10 min.Anesthesia  Etomidate  Short acting sedative hypnotic  Dose=0.  *Myoclonus .

30” HR.N/V.tonic/clonic.  Lasts approx.Ketamine  IM or IV  Glazed eyes &  Dissociative nystagmus anesthesia  Watch for agitated  Dose = 1-2 mg/kg recovery (IV)/ 4-10mg/kg IM  *Increased BP. hypersalivation .

 Sedative  1-2 mg IV  Onset 1.Anesthesia  Versed  Benzodiazepine. to 2H  *Hypotension .5 min.

Anesthesia  Fentanyl  Narcotic analgesic  50-100 mcg/kg  Lasts 30 min. depression .  *Resp.

short duration  Considerations: *Hypotension.Propofol (Diprivan)  Induction agent  Standard dose: 2 mg/kg  Rapid onset.apnea .

Paralytic (Neuromuscular block)  VECURONIUM  Skeletal Muscle Relaxer  0. .1 MG/KG IV(PARALYZING DOSE)  Lasts 25 to 45 min.

Dysthythmias  Malignant Hyperthermia . blocking agent muscle pain. vent.rhabdo.  Dose: 1 mg/kg hyper K.  Duration: 5 min. brady.Paralytic  SUCCINYLCHOLINE  Side effects:  Neuromuscular  Fasciculations.

Paralytic Contraindications  – Personal or family history of malignant  hyperthermia  – Significant. hyperkalemia is an  absolute contraindication  – End-stage renal disease / dialysis dependent  patients with unknown potassium level . verified.

5. Placement of Tube  Position patient • Do not bag unless SpO2 < 90% • Sellick’s Maneuver (Cricoid pressure) .

Placement of tube .

Placement and Proof  Confirm tube placement  – ETCO2  – Bilateral breath sounds  – Absent epigastric sounds .

Failed attempt What if the intubation attempt is not successful?  1st step = bag/mask ventilation for support Rescue Maneuvers  – The first rescue from failed intubation is bagging  – The first rescue from failed bagging is better bagging .

Post-intubation Management  Secure tube  ETCO2  Chest x-ray  Long acting sedation (+/.2mg/kg  – Propofol 25-50μg/kg/min  Establish ventilator parameters .paralysis)  – Midazolam 0.6.

6P’s RSI Summary • Preparation (zero – 10 minutes) • Preoxygenation (zero – 5 minutes) • Pretreatment (zero – 3 minutes) • Paralysis with induction (time zero) • Positioning (zero + 30 seconds) • Placement (zero + 45 seconds) • Post-tube management (zero + 90 seconds) .

Questions? .