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Rapid Sequence Induction


Rapid Sequence Induction CPT ... keep it close RSI Sequence PEARLS during the intubation Ensure continuous pulse oximetry If you are having difficulty passing ... – PowerPoint PPT presentation

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Title: Rapid Sequence Induction

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

  • 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

  • Identify the difference between a crash
    endotracheal intubation and RSI with endotracheal
  • 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

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!

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.

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 lt8
  • Persistent hypoxia (lt90)

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

  • 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!!

  • 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?

  • Develop RSI kits in the pre-deployment prep
  • These items need to be co-located and easy to get
  • 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

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

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

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

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

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

Required Medication
  • Narcotic
  • Remember, the paralyzed casualty will still feel
  • 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?

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

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

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
  • Requires refrigerationpossibly being
    re-manufactured in an unconstituted form
  • Not in your SKO

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
  • Comes in an unconstituted formdoes not require
  • Not in your SKO

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

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

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

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

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

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

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

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

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

RSI Sequence
  • Once you note paralysisIntubate
  • Once you get eyes on the cordsdont take them
  • 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

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

RSI Sequence
  • Tube verification
  • Visualized the tube passing between the cords
  • Auscultate lung sounds bilaterally with
  • 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
  • Chest x-ray (if you are at level II)

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

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

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
  • Keep it simple and leave that to the folks at
    Levels III/IV

Post Intubation
  • Keep them sedated and paralyzed
  • If the Succinylcholine wears offit will in about
    5 minutes, the casualty may start to fight the
  • 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
  • You should not consider extubating the casualty
    at levels I/IIleave that to the folks with more
    ICU experience/equipment and support.

  • 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

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