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Rapid Sequence Intubation


... ventilation is predicted to be successful Pharmacological Adjuncts Sedation Tranquilizers Barbiturates Benzodiazepines Narcotics Antianxiety and Sedative ... – PowerPoint PPT presentation

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Title: Rapid Sequence Intubation

Rapid Sequence Intubation
  • Optional, Paramedic

  • 1.1. Describe the indications, contraindications,
    advantages, disadvantages, complications, and
    equipment for rapid sequence intubation with
    neuromuscular blockade.
  • 1.2. Evaluate a patient who requires intubation
    and predict the difficulty of the intubation
    based on the patients physical findings.
  • 1.3. Identify neuromuscular blocking drugs and
    other agents used in rapid sequence intubation.

  • 1.4. Describe the indications, contraindications,
    advantages, disadvantages, complications, and
    equipment for sedation during intubation.
  • 1.5. Identify sedative agents used in airway
  • 1.6. Differentiate between Neuromuscular blocking
    Agents and their uses.

  • 1.7. Explain the pathophysiology of the agents
    used in RSI.
  • 1.8. Correctly calculate drug dosages of agents
    used in RSI.
  • 1.9. List the steps in Rapid Sequence Intubation.

  • Your Pt. is a 65 yo male with COPD who has been
    nebulizing at home while watching football for
    the last 6 hours without much success. He is
    tri-poding as you enter the room, his skin is
    pale, cool, and clammy, respirations at 42 and
    shallow. He can only say one word at a time,
    ascultation reveals wheezing with minimal breath
    sounds, the patient shows signs of air trapping.
    He shakes his head yes when asked have you been
    intubated before and do you want it again.

What would you do?
  • What would your next step be?
  • What is the pathophysiology of this patient?
  • The patient gets your attention points at his
    airway and colapses, apneic, what will you do?
  • When you attempt laryngoscopy without RSI the
    patients mandible is clenched with trismus. What
    are your options?
  • What medications and what doses would you give?

Evaluate the difficult airway
  • History
  • Deviated septum from Nasal fractures will make
    nasal tracheal intubation more difficult.
  • Neck Scars indicating potential changes to
    anatomical landmarks.
  • Physical Signs
  • Short muscular neck
  • Receding Chins
  • Overbite
  • Limited Mobility of the mandible
  • Oral Cavity - Malimapatti signs
  • Flexion and extension of the neck
  • External Larynx

  • One way to measure depth and mobility is to
    check the amount of available mandible.
  • More mandible will make visualizing the vocal
    cords easier.

Can the patient open their mouth far enough for 3
Mandible mobility
  • Can the patient position his lower teeth outside
    his upper teeth.

Visualizing the anterior airway
Malimapatti signs
Why Rapid Sequence Intubation
  • RSI is a technique that allows the Paramedic to
    control the airway of a patient that
  • Cant protect their own airway or otherwise
    requires paralysis to provide appropriate
  • Emergency intubation is warranted
  • The patient has a full stomach
  • Intubation is predicted to be successful
  • If intubation fails, ventilation is predicted to
    be successful

Pharmacological Adjuncts
  • Sedation
  • Tranquilizers
  • Barbiturates
  • Benzodiazepines
  • Narcotics

Antianxiety and Sedative-Hypnotic Agents
  • Antianxiety agents are used to reduce feelings of
    apprehension, nervousness, worry, or fearfulness
  • Sedatives and hypnotics are drugs that depress
    the CNS, produce a calming effect, and help
    induce sleep
  • The major difference between a sedative and a
    hypnotic is the degree of CNS depression induced
    by the agent. For example, a small dose to calm a
    patient is called a sedative a large dose of the
    same agent sufficient to induce sleep would be
    called a hypnotic. Therefore an agent may be both
    a sedative and a hypnotic, depending on the dose

Reticular formation
  • Reticular formation consists of groups of nuclei
    scattered through the brain stem
  • Reticular formation and its neural pathways
    constitute a system known as the reticular
    activating system (RAS)
  • Involved with the sleep-awake cycle
  • Through these pathways incoming signals from the
    senses and viscera are collected, processed, and
    passed to the higher brain centers
  • RAS determines the level of awareness to the
    environment and governs actions and responses to
  • Antianxiety and sedative-hypnotic agents and
    alcohol act by depressing the RAS

  • Benzodiazepines drug class most commonly used
    today to treat anxiety and insomnia
  • Barbiturates older drug class with many uses,
    from sedation to anesthesia

  • Benzodiazepines were introduced in the 1960s as
    antianxiety drugs today they are among the most
    widely prescribed drugs in clinical medicine.
    This popularity results in part from their very
    high therapeutic index. Overdoses of 1,000 times
    the therapeutic dose have been reported not to
    result in death unless taken in conjunction with
    other central nervous system depressants (e.g.,

Benzo functions and binding
  • Thought to work by binding to specific receptors
    in the cerebral cortex and limbic system (a major
    integrating system that governs emotional
  • Highly lipid-soluble and widely distributed in
    the body tissues
  • Highly bound to plasma protein (usually more than

  • Four actions
  • Anxiety-reducing
  • Sedative-hypnotic
  • Muscle-relaxing
  • Anticonvulsant
  • All benzodiazepines are schedule IV drugs because
    of their potential for abuse

Common Benzodiazepines
  • Flumazenil (Romazicon) is a specific
    benzodiazepine receptor antagonist and has been
    shown to be effective in reversing
    benzodiazepine-induced sedation and coma.
  • Alprazolam (Xanax)
  • Chlordiazepoxide (Librium)
  • Clorazepate (Tranxene)
  • Diazepam (Valium)
  • Flurazepam (Dalmane)
  • Prazepam (Centrax)
  • Midazolam (Versed)
  • Lorazepam (Ativan)
  • Triazolam (Halcion)

  • Once the most commonly prescribed class of
    medications for sedative-hypnotic effects, but
    they have been virtually replaced by
  • Divided into four classes according to their
    duration of action
  • Ultra-short-acting
  • Short-acting
  • Intermediate-acting
  • Long-acting

Ultra-short-acting barbiturates
  • Differences in onset and duration of action
    depend on their lipid-solubility and
    protein-binding properties
  • Ultra-short-acting barbiturates
  • Used as intravenous anesthetics
  • Act rapidly and can produce a state of anesthesia
    in a few seconds
  • Example thiopental sodium (Pentothal)

Short acting barbiturates
  • Short-acting barbiturates
  • Produce an effect in a relatively short time
    (1015 minutes) and peak over a relatively short
    period (34 hours)
  • Rarely used to treat insomnia
  • More commonly used for preanesthesia sedation and
    in combination with other drugs for psychosomatic
  • Examples include the following
  • Pentobarbital (Nembutal)
  • Secobarbital (Seconal)

Intermediate-acting barbiturates
  • Have an onset of 45 to 60 minutes and peak in 6
    to 8 hours
  • Short-acting and intermediate-acting agents have
    similar patient responses in the clinical setting
  • Examples include the following
  • Amobarbital (Amytal)
  • Butabarbital (Butisol)

Long-acting barbiturates
  • Require over 60 minutes for onset and peak over a
    period of 10 to 12 hours
  • Used to treat epilepsy and other chronic
    neurological disorders and to sedate patients
    with severe anxiety
  • Examples include the following
  • Mephobarbital (Mebaral)
  • Phenobarbital (Luminal)

Miscellaneous sedative-hypnotic drugs
  • Agents that are not benzodiazepines or
  • More similar to barbiturates than benzodiazepines
  • Examples include the following
  • Etomidate (Amidate)
  • Chloral hydrate (Noctec)
  • Ethchlorzynol (Placidyl)
  • Some antihistamines have pronounced sedative
  • Hydroxyzine hydrochloride (Vistaril, Atarax)

Pharmacological Adjuncts
  • Paralytic agents used for intubation
  • Depolarizing agents
  • Can lead to fasciculations
  • Succinylcholine (Anectine)
  • Nondepolarizing agents
  • Vecuronium (Norcuron)
  • Pancuronium (Pavulon)

Neuromuscular Blockers
  • Neuromuscular blockers produce skeletal muscle
    paralysis by binding to the nicotinic receptor
    for acetylcholine (ACh) at the neuromuscular
  • The neuromuscular junction is the point of
    contact between the nerve ending and the muscle
  • When nerve impulse pass through this junction,
    ACh and other chemicals are released, causing the
    muscle to contract
  • Two types of neuromuscular blocking drugs
  • Depolarizing agents
  • Nondepolarizing agents

Depolarizing Agents
  • Substitute themselves into the neuromuscular
    junction and bind to receptors for ACh
  • Because these drugs produce depolarization of the
    muscular membrane they often lead to
    fasciculations (uncontrollable muscle twitching)
    and some muscular contractions

  • Depolarizing agents block additional stimulation
    of the muscle fiber by remaining attached to the
    neuromuscular junction.
  • Complete muscle relaxation occurs in 30 seconds
    to 1 minute
  • Lasts for 2 to 3 minutes
  • Dissipates within 10 minutes.
  • This medication should be used cautiously in
    children because it may cause severe bradycardia
    or cardiac arrest. (Particularly in children with
    known neuromuscular disorders)

  • Rapid onset of action and briefest duration of
    action of all neuromuscular blocking drugs,
    making it the drug of choice for emergency
    endotracheal intubation.
  • Standard dose 1 to 1.5 mg/kg

Nondepolarizing agents
  • Bind to receptors for ACh and block the uptake of
    ACh at the neuromuscular junction, without
    initiating depolarization of the muscle membrane
  • Longer onset and duration than depolarizing
  • Examples
  • Vecuronium
  • Rapid onset2 minutes
  • Short duration45 minutes
  • Pancuronium
  • Rapid onset3 to 5 minutes
  • Longer duration1 hour

Dosing of Non-depolarizing Agents
  • Vecuronium
  • Adult
  • Pediatric
  • Pancuronium
  • Adult 0.04-0.1 mg/kg slow IV repeat q 30-60
    min prn
  • Pediatric 0.04-0.1 mg/kg slow IV
  • Newborn 0.02 mg/kg/dose
  • Contraindications-
  • Myasthenia Gravis

  • It is important to note that paralytic agents do
    not affect consciousness. It is vital to the
    patients continued health and psychological
    welfare that we sedate the patient continuously
    while they remain paralyzed.
  • Additionally remember that a patient in seizure
    remains in seizure despite the outward appearance
    induced by the paralysis. Adequate treatment via
    local protocol with an anti seizure agent such as
    Diazepam should be maintained despite paralysis.

  • Because these blocking agents produce complete
    paralysis, ventilatory support must be provided
    and the efficacy of ventilation and oxygenation
    closely monitored.
  • Atropine - (.02 mg/kg) should be strongly
    considered, to prevent vagus nerve stimulation
    potentially causing unwanted bradycardias.
  • Lidocaine - (1 to 1.5 mg/kg) may blunt any
    increase in intracranial pressure associated with
    intubation. Allow to circulate for 1 minute.

Rapid Sequence Intubation
  • Indications
  • Emergency intubation needed
  • Full stomach
  • Intubation likely to be successful
  • If intubation fails, ventilation possible

Six Ps of RSI
  • Preparation
  • Preoxygenation
  • Pretreatment
  • Paralysis (with induction)
  • Placement of the tube
  • Postintubation management

  • Start an IV
  • Initiate cardiac monitoring
  • Prepare your equipment
  • Suction.
  • ET Tube checked for leaks place stylet, attach 10
    to 15 cc syringe.
  • Laryngoscope blade checked size and light.
  • Set out ET Tube verification devices.
  • Prepare your medications and syringes
  • Be sure to label any medications you pull up in
    an unlabeled container (syringe)
  • Set out your cricothyrotomy kit as a backup.

  • Attempt pre-oxygenation of your patient with an
    increased FIO2 to achieve a PAO2 as high as

  • Begin your RSI with Pretreatment such as Atropine
    or Lidocaine. Allow time for the medication to
    take effect.
  • Pretreat with your sedative agent. Allow time for
    the sedative hypnotic to take effect.

Paralysis (with induction)
  • Administer your paralytic agent and allow time
    for the induction to occur usually less than 15
    to 30 seconds.
  • If utilizing succinylcholine observe the abdomen
    for fasciculation's.

Placement of the tube
  • Once you observe the paralysis of your patient
    open the airway manually and begin your
  • If the patients PAO2 drops below 80 or your PACO2
    begins to elevate above accepted levels via your
    local protocol stop intubation and ventilate your
    patient via BVM and increased FIO2 until with
    accepted limits.
  • Attempt intubation again.

Postintubation management
  • Once the tube has been placed confirm placement
    via visualization of thee cords, auscultation of
    bilateral breath sounds and ETCO2 detector or
    continuous CO2 wave form.
  • Secure the tube in place and ventilate.
  • Prepare to administer additional sedatives and/or
    longer acting paralytic agents depending on your
    local protocol.

What If
  • What if I cant get the tube?
  • Ventilate via BVM and increased FIO2.
  • What if I cant ventilate via BVM?
  • First of all then dont paralyze, if you have no
    choice then this is a good time to perform
  • What if my patient starts waking up during
    intubation attempts?
  • Go back to your pre-medication point and sedate
    the patient further then administer additional
    paralytic per local protocol.

Aspiration by Inhalation
  • Inhalation of food, foreign body, or fluid into
  • Suspect in patients with decreased level of
  • Aspiration is commonly lethal and will most
    likely be life changing if not lethal.
  • The introduction of an acidic substance into the
    lungs will cause destruction of alveoli and
    permanently change the lung parenchyma.
  • In response the body will constrict the post
    capillary sphincters in the effected tissues
    causing increased hydrostatic pressure and
    pulmonary edema.
  • It is our job to prevent aspiration by
    controlling the airway of the patient who cannot
    control their own.

  • Rapid Sequence Intubation is a technique to
    enable a Paramedic to control a patients airway.
  • Proper assessment of your patient and assessment
    of the potential risk to intubation can prevent
    unexpected complications.
  • Prepare your equipment and medications.
  • Utilize a device that ensures patency of the Et
  • Remember to sedate your patient before the last
    sedative has worn of.
  • Aspiration and Apnea kill patients it is our job
    to maintain the airway.
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