Rapid Sequence Intubation

Last Updated on by FRCEM Intermediate

Indications

  • A – airway protection and patency
  • B – respiratory failure (hypercapnic or hypoxic), increase FRC, decrease WOB, secretion management/ pulmonary toilet, to facilitate bronchoscopy
  • C – minimise oxygen consumption and optimize oxygen delivery (e.g. sepsis)
  • D – unresponsive to pain, terminate seizure, prevent secondary brain injury
  • E — temperature control (e.g. serotonin syndrome)
  • F — For humanitarian reasons (e.g. procedures) and for safety during transport (e.g. psychosis)

FACTORS THAT MAKE EMERGENCY INTUBATION DIFFICULT

  1. Dynamically deteriorating clinical situation, i.e., there is a real “need for speed”
  2. Non-cooperative patient
  3. Respiratory and ventilatory compromise
  4. Impaired oxygenation
  5. Full stomach (increased risk of regurgitation, vomiting, aspiration)
  6. Extremely short safe apnea times
  7. Secretions, blood, vomitus, and distorted anatomy

PROCESS OF RSI

Remembered as the 9Ps:

  • Plan
  • Preparation (drugs, equipment, people, place)
  • Protect the cervical spine
  • Positioning (some do this after paralysis and induction)
  • Preoxygenation
  • Pretreatment (optional; e.g. atropine, fentanyl and lignocaine)
  • Paralysis and Induction
  • Placement with proof
  • Postintubation management

Preparation

  • Oxygen
  • masks (NP, NRB, BVM);  monitoring
  • airway adjuncts (e.g. OPA, NPA, LMA); Ask for help and difficult airway trolley
  • RSI drugs; Resus drugs
  • BVM; Bougie
  • Laryngoscopes; LMA
  • ETTs; ETCO2
  • Suction; State Plan

Induction agents

  • Ketamine 1.5-2 mg/kg IBW
  • Etomidate 0.3-0.4 mg/kg TBW
  • Fentanyl 2-10 mcg/kg TBW
  • Midazolam 0.1-0.3 mg/kg TBW
  • Propofol 1-2.5 mg/kg IBW + (0.4 x TBW) (others simply use 1.5 mg/kg x TBW as the general guide)
  • Thiopental 3-5 mg/kg TBW

Neumuscular blockers:

  • Suxamethonium 1-2 mg/kg TBW
  • Rocuronium 0.6-1.2 mg/kg IBW
  • Vecuronium 0.15-0.25 mg/kg IBW

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