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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
- Dynamically deteriorating clinical situation, i.e., there is a real “need for speed”
- Non-cooperative patient
- Respiratory and ventilatory compromise
- Impaired oxygenation
- Full stomach (increased risk of regurgitation, vomiting, aspiration)
- Extremely short safe apnea times
- 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
Comparison Table
| Drug | Etomidate | Propofol | Thiopental | Ketamine |
|---|---|---|---|---|
| Dose | 0.3 mg/kg | 1.5–2.5 mg/kg | 2 – 7 mg/kg | 1 – 2 mg/kg |
| Onset | 5 – 15 secs | 20 – 40 secs | 5 – 15 secs | 15 – 30 secs |
| Recovery | 5 – 15 mins | 5 – 10 mins | 5 – 15 mins | 15 – 30 mins |
| CV depression | + | +++ | ++ | Minimal |
| Notes |
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