Rapid Sequence Induction

1. Rapid Sequence Induction

2. Rapid Sequence Induction (RSI) is the method used to secure the airway in a hemodynamically stable, spontaneously breathing patient. It is useful in patients who have a full stomach and therefore are at risk for aspiration. • Key Principles • Anticipating and retrieving the appropriate supplies and equipment. • Understanding and anticipating the sequence of events • Knowledge of the frequently used medications

3. Risk Factors for Aspiration • Last oral intake is unknown • Pregnancy • Agitated/Combative requiring diagnostic procedure • Traumatic injury-esp head injury • Intoxication • GI problems- Ex. Bowel Obstruction • Altered LOC with compromised airway

4. Aspiration is a serious complication that causes: • Increased length of stay • Increased cost of treatment • Increased chance of morbidity

5. Contraindications for RSI • Allergies to medications • Severe oral, mandibular or anterior neck trauma • Airway obstruction • Significant hypotension, profound shock state • Age less than 3 months

6. The goal of RSI is to rapidly secure and control the airway. Its all about TIME.

7. RSI Procedure • Prepare • Pre-oxygenate patient • Administer induction agent • Administer rapid acting muscle relaxant • Insert ET tube • Verify placement of ET tube and ensure airway is secured • Post intubation management

8. Supplies • Establish IV Access • Cardiac Monitor • Oxygen • Pulse Oximetry • Suction- Wall and Yankauer • Crash Cart • Ventilator Prepared for Attachment • Medications

9. Intubation Supplies • Bag value mask • Ambu bag • Assorted ET tubes- (size 7 or 8) • CO2 detector • Laryngoscope blades-Mac and Miller • Laryngoscope handle • Stylet • LMA • Bougie • Fiberoptic scope access • Cric or trach tray on standby

10. Patient Preparation • Brief history and assessment • Use the mnemonic AMPLE • A= Allergies • M= Medications • P= Past Medical History • L= Last Meal • E= Existing Circumstances

11. Patient Preparation • Pre-Oxygenation • 100% Oxygen- Non-rebreather mask or bag value mask • Pretreatment with medications to counteract the body’s response to intubation. Intubation causes • Increased ICP • Increased intraocular pressure • Hypertension and tachycardia

12. Paralysis with Induction • Induction/Sedation ALWAYS proceeds paralysis. • Induction agents should be administered by or under direct supervision of persons trained in the administration of general anesthetics and in the management of complications encountered during general anesthesia (anesthesiologist, ED physicians)

13. Cricoid Pressure • Application of pressure to the cricoid cartilage to occlude the esophagus. • Prevents the aspiration of gastric contents. • Do not release the pressure until instructed to do so.

14. Post Intubation • Monitor Vital Signs Frequently • Confirm Placement of ET Tube • End tidal CO2 • Auscultation • Chest X-ray • Secure ET Tube • Obtain Orders for Sedation and Pain Control • Obtain Vent Orders