RAPID SEQUENCE INDUCTION

(RSI/USE OF PARALYTIC AGENTS)

Level: Specially Trained EMT-P, RN

Indications: A critical need for airway control exists, such as:Any patient in respiratory arrest who have a gag reflex or

are clenched.Patients with severe head and facial injuries.Combative patients with compromised airways.Patients with depressed LOC.Patients with hypoxia refractory to oxygen (CPAP or

Supplemental Oxygen)Any time risk for potential/actual airway compromise is

suspected such as acute burn injury.Uncontrolled seizure activity (to provide airway control).Status asthmaticus nearing respiratory arrest.

Relative Contraindications:Patients in whom cricothyroidotomy would be difficult or

impossible (SHORT). Massive neck swelling/injury. Patients who would be difficult or impossible to

intubate/ventilate after paralysis. LEMON MOANS RODS SHORT

Acute epiglottitis. Upper airway obstruction. Known hypersensitivity to the drugs.

Note: The benefit of obtaining airway control must always be weighed against the risk of complications in these patients.

COMPLICATIONS ASSOCIATED WITH INTUBATION

Increased intragastric pressure (emesis). Bradycardia/asystole (especially in children less than 1 yr not

premedicated with Atropine.) Malignant hyperthermia. Prolonged apnea. Inability to intubate/ventilate after paralytic administration. Hypotension. Aspiration. Dysrhythmias. Fasciculations. Histamine flush Tachycardia. Hyperkalemia. Inability to recognize decreased neurologic status. Bronchospasm

USE THE FOLLOWING TO DETERMINE DIFFICULT AIRWAY:

LEMON (Predicts difficult laryngoscopy).

MOANS (Predicts difficult mask ventilation).

RODS (Predicts difficult EGD).

SHORT (Predicts difficult cricothyrotomy).

LEMON (Difficult Laryngoscopy)

Look externally

Evaluate 3 – 3 – 2 rule

Mallampati

Obstruction/Obesity

Neck mobility

MOANS (Difficult Mask Vent)

Mask Seal

Obese

Aged (> 55 years old)

No teeth

Stiff (increased ventilatory pressures, e.g. asthma, COPD, ARDS,term pregnancy)

RODS (Difficult EGD)Restricted mouth opening

Obese

Distorted airway

Stiff as in MOANS

SHORT (Difficult Cricothyrotomy)Surgery (previous)

Hematoma

Obese

Radiation

Tumor

PreparationAssemble necessary equipment:

Suction

BVM with correct sized mask

Working suction equipment

Appropriate sized ET tubes

Working laryngoscope

Appropriate drugs drawn up in syringes

Pulse oximeter

End-tidal CO2 monitoring device

Have cricothyroidotomy equipment readily available.

Preparation cont.

Assess patient for possible difficult intubation via LEMON, MOANS, RODS, and SHORT.

If there is a potential for a difficult airway, go to the Difficult

Airway Algorithm PAGE 488.

Position patient properly in sniffing position or use in-line stabilization if indicated.

Assure at least one secure well running IV line.

Connect patient to cardiac monitor and pulse oximeter.

Assign specific duties to personnel on scene (i.e., assistance with bagging, pushing of medications.)

Pre-OxygenationPlace patient on continuous oxygen via nasal

cannula at 6 lpm. Once the patient is sedated and/or paralyzed, increase the flow rate to 15 lpm via nasal cannula. Continue nasal cannula oxygen throughout your intubation attempt while patient is paralyzed.

Pre-oxygenate for three minutes via BVM (leave nasal cannula in place until patient is intubated). This establishes oxygen reservoir:Flushes out nitrogen Increases functional residual capacity of lung.

Once intubated, discontinue the nasal oxygen.When adequately preoxygenated, a healthy 70 kg

adult can remain apneic for up to 6-8 minutes.Children experience oxygen desaturation more

quickly due to their fast metabolism.Obese patients experience oxygen desaturation

more quickly due to adipose tissue metabolizing faster.

Pre-Treatment

Pre-medicate as appropriate:

Lidocaine 1.5 mg/kg IVP 2 - 3 minutes before intubation:

For possible head injury patients, to mitigate increased intracranial pressure (ICP) which may occur during intubation.

For patients with reactive airway disease, i.e. severe asthma.

For dysrhythmia control in patients at risk for ventricular dysrhythmias.

NOTE: Lidocaine is contraindicated if there is known hypersensitivity to the drug.

Pre-Treatment cont.

Fentanyl 3 mcg/kg (~200 mcg IV in average adult) Given as the last pre-treatment drug. Administer over 30 – 60 seconds.

Give as pre-medication for suspected head injury or increased intracranial pressure.

DO NOT use on children under the age of 10.

Atropine 0.02mg/kg/IV (max 1 mg) – for children less than 12 months receiving RSI.

Paralysis with Induction

Induce with ONE of the following:

Amidate (Etomidate) 0.3 mg/kg IV push for sedation.NEVER REPEAT ETOMIDATE- NEVER REPEAT ETOMIDATE- NEVER REPEAT ETOMIDATE

Versed 0.10 - 0.15 mg/kg IVP for awake patients to achieve amnestic effect. Pediatric dosage is 0.03 mg/kg.

Versed is contraindicated if the patient is hypotensive. Alternative drug: Valium 2-10 mg IVP

Ketamine (Ketalar) 1 – 2 mg/kg IV (last resort 4 mg IM) First choice for reactive airway disease.

Paralyze with one of the following:

Anectine (Succinylcholine - depolarizing) 1.5mg/kg IV over 10- 30 sec

NOTE: Onset 30 – 45 seconds. Duration 4 – 10 minutes.

Rocuronium (Zemuron - non-depolarizing) 1mg/kg IV in adults

Children 0.6mg/kg IV NOTE: Onset 45 – 60 seconds. Duration: 20 – 90 minutes.

Succinylcholine

Use NON-Fasciculating agent (Rocuronium) on patients at risk for or having problems related

to:

Hyperkalemia (elevated potassium). Only if EKG Changes show peaked T waves or wide QRS.

Penetrating eye injuries (do not use depolarizing blocker).

History of malignant hyperthermia.

Unstable fractures (secondary to muscle fasciculation).

PARALYZE CONT.

Once paralytic has been given IV, discontinue bagging patient with BVM and monitor pulse ox. It is not necessary to resume bagging patient until patient is intubated (at which time you ventilate with ambu-bag via the ET tube) or the oxygen saturation drops below 91%, at which time you re-oxygenate before trying to intubate again.

Proper pre-oxygenation will allow you 6-8 minutes of allowable apnea to intubate.

Perform controlled endotracheal intubation with in-line stabilization if indicated.

TECHNIQUE OF ENDOTRACHEAL INTUBATION

Position the patient supine, open the airway.

Open mouth by separating the lips and pulling on upper jaw with the index finger.

Hold laryngoscope in left hand, insert scope into mouth with blade directed to right tonsil.

Once right tonsil is reached, sweep the blade to midline keeping the tongue on the left. This brings epiglottis into view. “DO NOT LOSE SIGHT OF IT!”

Advance the blade until it reaches the angle between the base of the tongue and epiglottis (vallecular space).

TECHNIQUE OF ENDOTRACHEAL INTUBATION CONT.Lift the laryngoscope upwards and away from the nose – towards the chest. This should bring the vocal cords into view. It may be necessary for a colleague to press on the trachea to improve the view of the larynx.

Place the ETT in the right hand, keeping the concave side of the tube facing the right side of the mouth.

Insert the tube, just so the cuff has passed the vocal cords and then inflate the cuff.

Using a stethoscope, listen for air entry at both apices and both axillae to ensure correct placement.

Paralyze cont. Confirm placement by auscultating for bilateral breath sounds,

checking oxygen saturations, and by checking for presence of end-tidal carbon dioxide (ETCO2) or any three methods in the confirmation protocol.

If intubation is unsuccessful, remove the tube and ventilate the patient with 100% oxygen via a BVM until ready to attempt re-intubation. You should be able to successfully use a BVM to oxygenate the patient or successfully ventilate until the effects of the paralytic are gone. Prepare to suction emesis.

Maintain cervical immobilization if necessary.If after 1-2 repeat intubation attempts fail, go to failed airway

algorithm (4.34 SMART AIRWAY MANAGEMENT), which calls for using and extra-glottic device or performing a cricothyrotomy. If an extra-glottic device can be inserted or the patient’s oxygen saturation can be maintained > 91% with an oral pharyngeal airway and BVM, transport to hospital.

Only perform a cricothyrotomy if unable to ventilate and unable to maintain pulse ox > 91%.

IF INADEQUATE RELAXATION IS PRESENT

ADMINISTER SECOND DOSE OF:

Anectine (Succinylcholine) 0.6mg/kg IV

Rocuronium is long acting, therefore second dose not needed.

Post Intubation Management

Once intubation is completed and tube placement is confirmed, inflate the cuff and continue to ventilate with 100% oxygen via BVM.

Secure ET tube in place. Keep patient sedated with one of the following: Versed 2 – 4 mg IV initial, then titrate 1 mg increments prn Morphine 2-5 mg IV, then titrate 2 mg increments prn Ketamine 0.25 to 0.5 mg/kg IV every 5 to 10 min prn

Continued paralysis will only be ordered by medical control.

Post Intubation ManagementProper endotracheal tube placement must be documented by at least three different methods. These include:Presence of bilateral breath sounds.Absence of breath sounds over the epigastrium.Checking oxygen saturations.Presence of condensation on the inside of the endotracheal tube.

End-tidal carbon dioxide monitoring.Use of an endotracheal esophageal detector (if available).

Visualizing the tube passing through the cords.Bilateral, symmetrical expansion of the thorax.

At least three verification methods must be documented in the medical record!

Considerations:

Once a neuromuscular blocking agent is given, you assume complete responsibility for maintaining an adequate airway and ventilations.

Have your backup airway (King Airway) available to use if unable to intubate.

Be prepared to perform a surgical airway if intubation cannot be executed and ventilation with a BVM is not possible. (This will be rare.)

Continuously monitor oxygen saturations and end-tidal carbon dioxide.

FACILITATED INTUBATION IS NOT RSI WITHOUT THE PARALYTIC!

THERE IS STILL A RISK OF THE PATIENT VOMITING BECAUSE THE PATIENT IS SEDATED, NOT PARALYZED.