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Rapid Sequence Intubation. Neil Laws CareFlite Ft. Worth. Objectives. Indications Contraindications Complications Pharmacology Procedure. Indications. Patients who cannot tolerate awake intubations. Combative patients with compromised airways. Patients with depressed LOC

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Rapid sequence intubation

Rapid Sequence Intubation

Neil Laws

CareFlite Ft. Worth


Objectives
Objectives

  • Indications

  • Contraindications

  • Complications

  • Pharmacology

  • Procedure


Indications
Indications

  • Patients who cannot tolerate awake intubations.

  • Combative patients with compromised airways.

  • Patients with depressed LOC

  • Severe head trauma with the need for airway control and hyperventilation.


Indications1
Indications

  • Need to decrease myocardial oxygen demand.

  • Uncontrolled seizure activity

  • Status asthmaticus nearing respiratory arrest

  • Anytime risk for potential/actual airway compromise is suspected.


Absolute contraindications
Absolute Contraindications

  • Patients in whom Cricothyroidotomy would be difficult or impossible:

    • Children less than 2 years of age

    • Massive neck swelling/injury

  • Patients who would be difficult/impossible to intubate:

    • Acute epiglottitis

    • Upper airway obstruction


Relative contraindications
Relative Contraindications

  • Known hypersensitivity to the drug

  • Penetrating eye injuries

  • History of malignant hyperthermia

  • Hyperkalemia

  • Unstable fractures


Complications
Complications

  • Increased intragastric pressure

  • Bradycardia/Asystole

  • Malignant hyperthermia

  • Prolonged apnea

  • Inability to intubate/ventilate

  • Hypotension

  • Aspiration

  • Increased intraocular pressure


Preparation
Preparation

  • Assemble necessary equipment (suction, BVM, working laryngoscope and appropriate sized ET tube, drugs/syringes, pulse oximeter, cardiac monitor, O2)

  • Assure at least one well running IV line

  • Connect patient to pulse ox and monitor

  • Assign duties (cric pressure, pushing of meds, bagging, etc.)

  • Position patient properly


Oxygenation

It is ideal to let the patient spontaneously breathe 100% O2 for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

If the patient is not breathing adequately, or you are unable to wait 4-5 minutes, 4 vital capacity breaths are adequate. 1-2 minutes of preoxygenation with 100% O2 is preferred.

Oxygenation


Pharmacology
Pharmacology for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.


Medications used in rsi
Medications used in RSI for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Lidocaine

  • Versed

  • Valium

  • Atropine

  • Anectine / Succinylcholine

  • Norcuron / Vecuronium


Lidocaine
Lidocaine for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Lidocaine is used in the RSI setting 2-3 minutes prior to intubation to control ICP in patients with possible head injuries, patients with CNS pathologies (hypertensive crisis, or bleed), and dysrhythmia control

  • Dosage: 1.5 mg/kg IVP

  • Pedi dosage: 1.5 mg/kg IVP


Versed
Versed for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Versed is one agent used to sedate the patient and also to achieve an amnesic effect. It is a short acting Benzodiazepine that has sedative and anesthetic properties. Versed will depress the respiratory system.

  • Benzodiazepines are contraindicated in the presence of hypotension.

  • Dosage: 5 mg IVP

  • Pedi dosage: 0.1 mg/kg IVP


Valium
Valium for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Valium is also a short acting Benzodiazepine that is used to sedate the RSI patient prior to administration of the paralytic agent. Valium does not seem to have the same amnesic effects of Versed.

  • Valium does depress the respiratory system.

  • Dosage: 5 mg IVP

  • Pedi dosage: 0.2 mg/kg IVP


Atropine
Atropine for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Atropine is used on the adult patient exhibiting bradycardia.

  • Atropine is given prophylacticly to pediatric patients less than 8 years old.

  • Dosage: 0.5 mg IVP

  • Pediatric dosage: .01-.02 mg/kg


Succinylcholine
Succinylcholine for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Will be used to induce paralysis in adults and children.

  • Short acting depolarizing neuromuscular blocking agent that relaxes and paralyzes skeletal muscle

  • Has NO effect on pain threshold or LOC

  • Muscle fasiculations are a potential problem

  • Dosage: 1.5 mg/kg IVP

  • Pedi dosage: 2.0 mg/kg in pedi pt. <3 y/o


Norcuron
Norcuron for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Norcuron is a non-depolarizing neuromuscular blocking agent that is used to maintain paralysis of the patient ONLY after the absolute confirmation of correct tube placement.

  • Several indicators should be used to confirm placement.

  • Dosage: 0.1 mg/kg IVP Adult and Pedi

  • Repeat dosage: .05 mg/kg IVP


Procedure
Procedure for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.


Procedure1
Procedure for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Preoxygenate patient with 100% O2 by non-rebreather mask or by BVM as patient condition permits

  • Premedicate as is appropriate:

    • Lidocaine

    • Versed / Valium

    • Atropine


Procedure2
Procedure for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Administer Succinylcholine

  • Apply cricoid pressure to occlude the esophagus until intubation is successfully completed and the cuff is inflated.

  • Continue to oxygenate the patient with 100% O2 for 1-2 minutes allowing sedation to take effect. Jaw relaxation and decreased resistance to manual ventilation's are indicators that the patient is ready to be intubated.


Procedure3
Procedure for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Be prepared to suction

  • Perform a controlled intubation with in-line stabilization, if indicated.

  • Confirm placement of tube, secure.

  • If intubation is unsuccessful, remove tube and ventilate the patient with 100% O2 (hyperoxygenate) until ready to re-attempt


Procedure4
Procedure for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • It may be necessary to re-medicate the patient with succinylcholine.

  • Maintain C-spine immobilization

  • If repeated intubation attempts fail, ventilate the patient with 100% O2 via BVM until spontaneous respiration's return, or if you are unable to adequately ventilate the patient you will need to perform a cricothyroidotomy.


Procedure5
Procedure for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • Once intubation is completed and tube placement is confirmed, inflate the cuff, release cric pressure, secure the tube, note tube depth for documentation, all while continuing to ventilate with 100% O2.

  • Following confirmation of intubation, administer 0.1 mg/kg vecuronium (Norcuron) IVP.


***** for 4-5 minutes to wash out the nitrogen reservoir and establish an oxygen reservoir.

  • It is important to note that once a neuromuscular blocking agent is given, the paramedic assumes complete responsibility for maintaining an adequate airway and ventilations. O2 sats and ETCO2 levels must constantly be monitored. The paramedic must always be prepared to perform a surgical airway if intubation cannot be done, and ventilation with a BVM is no possible.


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