Rapid Sequence Induction

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Rapid Sequence Induction

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

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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

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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

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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!

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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.

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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 (

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6 P's of RSI

• Preparation
• Preoxygenation
• Pretreatment
• Paralysis (with induction)
• Placement of the tube
• Post intubation management

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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!!

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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?

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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

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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

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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

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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

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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

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Required Medication

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

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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?

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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

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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

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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

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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

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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

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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

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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

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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

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RSI Sequence

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

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RSI Sequence

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

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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

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RSI Sequence

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

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RSI Sequence

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

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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

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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

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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)

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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

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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

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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

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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.

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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

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Questions??