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Rapid Sequence Induction

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Test and set up your ET tube ... You want to visualize the tube passing between the cords. Ensure someone places the tube into your hand. You WILL have to use ... – PowerPoint PPT presentation

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Title: Rapid Sequence Induction


1
Rapid Sequence Induction
  • CPT James Rice, PA-C
  • Program Manager
  • Tactical Combat Medical Care

2
References
  • Emergency Medicine, A Comprehensive Study Guide,
    Tintinalli, 6th ed., McGraw-Hill, 2004
  • Emergency War Surgery, Third United States
    Revision, Chapter 9, Borden Institue, Walter Reed
    Army Medical Center

3
Objectives
  • Identify the difference between a crash
    endotracheal intubation and RSI with endotracheal
    intubation.
  • Identify the indications for RSI
  • Discuss concepts in preparing your trauma team
    for RSI
  • Identify the equipment and medication required
    for RSI
  • Discuss the steps in performing RSI

4
Crash vs. RSI
  • Crash endotracheal intubation
  • No use of medication to facilitate the procedure
  • The casualty is unconscious, unresponsive and has
    no gag reflex.
  • EMERGENCYcan be a flail!

5
Crash vs. RSI
  • 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 casualty vomit and aspirate.

6
Indications for RSI
  • Impending airway obstruction
  • Facial fracturesno excessive oral bleeding
  • Facial burnsinhalation injury
  • Expanding retropharyngeal hematoma
  • Excessive work of breathing
  • Examplethe exhausted asthmatic
  • Shock
  • GCS
  • Persistent hypoxia (

7
6 P's of RSI
  • Preparation
  • Preoxygenation
  • Pretreatment
  • Paralysis (with induction)
  • Placement of the tube
  • Post intubation management

8
Preparation
  • Remember that RSI is a team effort
  • Intubationist
  • IV/med person
  • Suction/ET tube person
  • Cricoid pressure
  • Fish hook
  • O2 Sat person
  • You should have all of these jobs identified and
    rehearse, rehearse, rehearse!!

9
Preparation
  • Always have a back-up airway intervention!!!
  • After 2 attempts at passing the tubeyou probably
    arent going to get it
  • Surgical cric is an excellent option
  • Have a cric kit ready
  • How are you going to ventilate the casualty once
    you have the airway secured?
  • Ventilator?
  • Medic?
  • Non-medic?

10
Preparation
  • Develop RSI kits in the pre-deployment prep
  • These items need to be co-located and easy to get
    to
  • Meds
  • Laryngoscope/blades/batteries/bulbs
  • Need to be checked daily
  • Suctionwith rigid suction tip
  • Needs to be checked daily
  • ET Tubes/stylets/syringe
  • Tape (with tongue blade)
  • J-tube
  • Ventilator if you have it
  • Make sure you have all the components and check
    it daily
  • O2

11
Required Equipment
  • Laryngoscope handle
  • Recommend the pediatric handlesmaller, lighter
  • Laryngoscope blades
  • Several sizes
  • Macintosh vs. Miller is personal preference
  • Batteriestake a bunch
  • Laryngoscope blade bulbstake a bunch

12
Required Equipment
  • ET tubes
  • Various sizes
  • Dont forget some pedi sizes (no cuffs!)
  • ET tube stylets
  • 10cc syringe
  • 3 inch tape
  • Wrap it over a tongue blade

13
Required Equipment
  • Suction
  • Absolutely required!!
  • Suction catheter
  • Keep it with the suction apparatus
  • J-tube
  • Prevent the casualty from biting the tube
  • Oral-Gastric tube

14
Required Equipment
  • O2 sat monitor
  • Cardiac monitor
  • Nice to have
  • AMBU bag
  • Can hook up the O2 and use it as a mask
  • IV kit
  • Portable Ventilator
  • Nice to have
  • Surgical cric kit

15
Required Medication
  • Narcotic
  • Amnestic, Anxiolytic
  • Sedative
  • Paralytic(s)

16
Required Medication
  • Narcotic
  • Remember, the paralyzed casualty will still feel
    pain!
  • Morphine 5-10mg load and then titrate at 2mg
    every 5 min to effect
  • Readily available
  • Fentanyl?
  • Effective with virtually no CV effects
  • Currently recommended, but not readily available
    in SKO
  • Should we have Narcan readily available?

17
Required Medication
  • Anxiolytic/Amnestic
  • Versed 5mg slow IV push
  • Good amnestic effect
  • Readily available
  • May cause hypotension in the shocky casualty
  • Sedative
  • Etomidate 0.3mg/kg IV
  • Good sedative with good side effects profile
  • The most common sedative in the ER setting
  • Does not require refrigeration
  • Is NOT in your SKO currently

18
Required Medication
  • Lidocaine
  • 1mg/kg IV
  • Blunt the rise in ICP associated with intubation
  • Recommended in the head trauma casualty, although
    no data to support this effect
  • Atropine
  • 0.02mg/kg IV (min dose 0.10mg)
  • Children
  • Blunts the reflex bradycardia and helps dry up
    secretions

19
Required Medication
  • Paralytics
  • Succinylcholine
  • 1.0mg/kg IV
  • Depolarizing
  • Onset in 30-60 seconds
  • 5-10 minute duration
  • Can cause fasciculations, bradycardia, elevated
    ICP, elevated intragastirc pressure and malignant
    hyperthermia
  • Requires refrigerationpossibly being
    re-manufactured in an unconstituted form
  • Not in your SKO

20
Required Medication
  • Vecuronium
  • 0.1mg/kg IV (paralytic dose)
  • Non-depolarizing
  • 2-3 minute onset
  • 30-40 minute duration
  • A dose of 0.01mg/kg is a very effective way to
    prevent the fasciculations associated with
    succinylcholine
  • Comes in an unconstituted formdoes not require
    refrigeration
  • Not in your SKO

21
Required Medication
  • O2
  • Understand you dont have a lot
  • Be conservative in regard to using your oxygen
    for the medical emergency or trauma patient who
    is NOT hypoxic
  • Attach it up to your AMBU bag, then use the AMBU
    bag as a face mask during the set up/prep and
    pre-medication phases
  • Applying PPV is not necessary and not recommended
    unless the casualty isnt breathing

22
Required Medication
  • NS
  • Often overlooked by the non-nurse
  • Required to flush the IV site after administering
    IV push meds
  • Simply have 15cc of NS in a syringe and flush the
    IV site with 5cc after administering the IV med

23
RSI Sequence
  • Set-Up/Preparation-key!!!
  • Gather your team and ensure everyone understands
    their job!
  • Get at the head of the bed
  • Start directing traffic-KEEP CALM!!
  • Gather your RSI kit
  • Preoxygenate
  • Reconstitute meds/draw up NS in a 15cc syringe
  • Ensure a patent IV site
  • Attach pulse oximeter

24
RSI Sequence
  • Set-Up/Preparation-key!!!
  • Re-test your laryngoscope (should have been
    tested already)
  • Test and set up your ET tube
  • Have suction VERY CLOSE and turned on with
    suction catheter attached
  • Optimize the casualties head/neck position

25
RSI Sequence
  • Pre-medication Phase
  • Morphine
  • Versed
  • Lidocaine
  • Atropine

26
RSI Sequence
  • Pre-medication Phase
  • Defasciculation (optional)
  • Vecuronium 0.01mg/kg

27
RSI Sequence
  • Cricoid pressure (Sellick Maneuver)
  • Prevents aspiration
  • Helps bring the cords into view
  • Avoid compressing the carotids
  • Hold steady firm pressure until the intubation is
    complete, the cuff is inflated and you have
    confirmed tube placement!!!
  • Bad form to allow the casualty to aspirate when
    we are doing an RSI to prevent aspiration

28
RSI Sequence
  • Sedate
  • Etomidate
  • Wait about a minute, you should be able to
    appreciate the sedative effect

29
RSI Sequence
  • Paralytic
  • Succinylcholine
  • You should note paralysis within 60 seconds
  • Vecuronium
  • You should note paralysis in 2-3 minutes

30
RSI Sequence
  • Once you note paralysisIntubate
  • Once you get eyes on the cordsdont take them
    off!
  • You want to visualize the tube passing between
    the cords
  • Ensure someone places the tube into your hand
  • You WILL have to use the suctionkeep it close

31
RSI Sequence
  • PEARLS during the intubation
  • Ensure continuous pulse oximetry
  • If you are having difficulty passing the tube and
    the pulse ox reading falls to the
    mid-eightiesstop the procedure and begin
    ventilating the casualty to a better state of
    oxygenation and then try again
  • If you cant successfully intubate after 2
    attemptsstop and do a surgical cric

32
RSI Sequence
  • Tube verification
  • Visualized the tube passing between the cords
  • Auscultate lung sounds bilaterally with
    ventilation
  • Fog in the tube with exhalation
  • Palpate the tube within the trachea (possibly)
  • Casualties oxygenation has improved or is
    maintained in the mid to upper 90s
  • CO2 detector attached to the tube (if you have
    it)
  • Chest x-ray (if you are at level II)

33
Post Intubation
  • The casualty needs to be ventilated
  • That can be for a prolonged period of time
  • Medic?
  • Non-medic?
  • Ventilator?
  • Secure the tube
  • A J-tube may be inserted
  • Prevent biting of the tube
  • An oral gastric tube should be inserted
  • Decompress the stomach

34
Post Intubation
  • Ventilation
  • Medic or non-medic
  • 12-20 breaths per minute
  • Disconnect the O2 and re-evaluate after several
    minutesyou have limited O2 assets
  • Watch the pulse ox
  • Protect the tube

35
Post Intubation
  • Ventilator
  • Basic settings
  • Tidal volume 10cc/kg
  • Healthy lungs
  • Resp rate 12-16/min
  • PEEP of 5cm
  • O2 100 (if you have an abundance)
  • These are start points, you do not have the
    ability to track ABGs and fine tune your
    settings
  • Keep it simple and leave that to the folks at
    Levels III/IV

36
Post Intubation
  • Keep them sedated and paralyzed
  • If the Succinylcholine wears offit will in about
    5 minutes, the casualty may start to fight the
    tube/ventilation
  • Consider giving or maintaining the casualty on
    Vecuroniumdont forget giving some more Morphine
    and Versed
  • This will keep them paralyzed/sedated throughout
    the evac system
  • Would you like to be paralyzed without
    sedation/analgesia?
  • You should not consider extubating the casualty
    at levels I/IIleave that to the folks with more
    ICU experience/equipment and support.

37
Summary
  • RSI is a controlled procedure
  • RSI requires a team effort
  • Pre-planning and prep is absolutely key
  • Rehearse, rehearse, rehearse!!!
  • Medication options
  • Steps in performing RSI
  • Post intubation concepts

38
Questions??
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