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Rapid Sequence Intubation

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Intro to: Objectives Define RSI Identify the Indicators for using RSI Identify the relative contraindications and disadvantages of RSI Discuss the different roles in ... – PowerPoint PPT presentation

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Title: Rapid Sequence Intubation


1
Rapid Sequence Intubation
  • Intro to

2
Objectives
  • Define RSI
  • Identify the Indicators for using RSI
  • Identify the relative contraindications and
    disadvantages of RSI
  • Discuss the different roles in the RSI process
  • Review the crucial 7 Ps of RSI
  • Review the medications used during RSI
  • Review a difficult airway and identify
    alternative tools and techniques

3
What is RSI?
4
Why RSI?
  • Respiratory failure
  • Inability to protect own airway
  • Impending or potential airway compromise
  • GCS less than 8
  • Intractable seizures

5
Relative contraindications to RSI
  • Airway obstruction
  • Distorted anatomy
  • Major facial or laryngeal trauma
  • Angioedema

6
Disadvantages of RSI
  • Hypoxia if unable to complete intubation
  • RSI blocks the patients involuntary reflexes and
    muscle tone in the oropharynx and larynx
  • Adverse medication reactions
  • Masks underlying symptoms
  • Requires considerable amount of training and
    recurrent training

7
  • The benefit of obtaining airway control must
    always be weighed against the risk of
    complications in these patients.
  • You are taking a breathing patient and making
    them APNEIC

8
RSI Equipment
  • Airway equipment (ET, syringe, stylette, etc)
  • Oxygen
  • Suction equipment
  • Ecg monitor
  • IV equipment
  • SaO2 monitor
  • Capnography
  • RSI meds

9
Its a team effort!
  • Skilled intubator
  • Timekeeper/scribe
  • Vital sign monitor
  • Medication administrator
  • Assistant

10
Before you get started. In the ideal world
  • Get medical history
  • Obtain baseline neuro exam
  • Check all your equipment
  • Confirm pt. weight

11
7 Essential Ps of RSI
  • Preparation
  • Pre-oxygenate
  • Pre-medicate
  • Paralysis and Induction
  • Protection
  • Placement of the tube
  • Post Intubation management

12
Preparation
  • Prepare all equipment including ETT, suction,
    pulse oximeter, IV and monitor
  • Position patient in sniff position if C-spine
    immobilization is not indicated.

13
Pre-Oxygenate
  • Pre-oxygenate with 100 oxygen via NRB for at
    least 3 min. or 8 vital capacity breaths with
    100 oxygen.
  • If ventilatory assistance is necessary with BVM,
    be gentle and apply cricoid pressure.

14
Do you predict a difficult airway?
  • Short neck or no neck
  • Small mandible
  • Obesity
  • Facial/maxillary trauma
  • Edema or infection
  • Degenerative spinal disease

15
What does a difficult airway mean to you?
  • Be prepared!
  • Have plan B, C, and D if intubation fails.

16
Tools for a difficult airway
  • Have one ETT tube size smaller bigger available
  • ETTI (Bougie, Eshman, etc)
  • Back up devices (Combitube, King airway)
  • Surgical airway kit

17
Are you ready?
18
What drugs do we use?
  • Oxygen
  • Ventilate while preparing for RSI
  • Lidocaine?
  • Atropine?
  • Versed
  • Etomidate
  • Succinylcholine
  • Vecuronium

19
Procedure
  • Pre-oxygenate (NOT hyperventilate) for 2 3
    min.
  • Assemble equipment
  • Proximal IV preferred
  • Connect pt. To monitor
  • Lidocaine (TBI)
  • Atropine (children lt 10)
  • Versed
  • Etomidate
  • Succinylcholine
  • Sellick maneuver

20
Procedure, cont.
  • Stop ventilations
  • Observe for fasiculations
  • Intubate
  • If unable to ventilate in 20 sec. , stop and
    ventilate for 30 60 sec.
  • May give second dose of Sux (1 1.5 time initial
    dose
  • If bradycardia occurs, give Atropine and
    hyperventilate
  • Confirm intubation
  • Attach Easy Cap or capnography device
  • Administer Vecuronium
  • MONITOR PATIENT

21
Protect the Patient
  • Maintain cervical stabilization prn
  • Maintain cricoid pressure until tube placement is
    confirmed and secured.
  • Constant vigilance of monitoring oxygenation

22
Whose tube is it?
  • The most experienced medic!
  • If unable to intubate within 20 seconds or SaO2
    drops below 92, STOP and ventilate with BVM
  • Confirm placement
  • Release cricoid pressure

23
How did you confirm the tube?
  • Gold standard (visualized tube passing through
    the cords
  • Capnography
  • Mist in the tube
  • Bilateral breath sounds
  • Recheck tube placement after every patient move,
    if airway resistance occurs or increases, hear
    rate decreases, or O2 desaturation occurs

24
Post medication
  • Continue paralysis with Vecuronium
  • Continue sedation with Versed
  • Consider pain control

25
What if you cant get the tube in??
  • Provide 100 oxygen with BVM
  • Consider back up device
  • Consider surgical airway

26
All neuromuscular Blocking Agents
  • Work by blocking the natural transmission of
    nerve impulses to skeletal muscles.
  • No direct effect on Heart, Digestive system,
    Brain, Pupillary response, Smooth Muscle or
    other organ systems
  • No effect on mentation or pain perception!
  • No direct effect on seizure activity.

27
Remember.
  • If performed correctly, RSI will take between 7
    10 minutes.
  • You are taking a breathing patient and making
    them apneic.
  • Always be prepared and know your RSI protocol.
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