Rapid Sequence Intubation

1. Rapid Sequence Intubation Neil Laws CareFlite Ft. Worth

2. Objectives • Indications • Contraindications • Complications • Pharmacology • Procedure

3. 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.

4. Indications • Need to decrease myocardial oxygen demand. • Uncontrolled seizure activity • Status asthmaticus nearing respiratory arrest • Anytime risk for potential/actual airway compromise is suspected.

5. 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

6. Relative Contraindications • Known hypersensitivity to the drug • Penetrating eye injuries • History of malignant hyperthermia • Hyperkalemia • Unstable fractures

7. Complications • Increased intragastric pressure • Bradycardia/Asystole • Malignant hyperthermia • Prolonged apnea • Inability to intubate/ventilate • Hypotension • Aspiration • Increased intraocular pressure

8. 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

9. 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

10. Pharmacology

11. Medications used in RSI • Lidocaine • Versed • Valium • Atropine • Anectine / Succinylcholine • Norcuron / Vecuronium

12. Lidocaine • 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

13. Versed • 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

14. Valium • 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

15. Atropine • 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

16. Succinylcholine • 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

17. Norcuron • 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

18. Procedure

19. Procedure • Preoxygenate patient with 100% O2 by non-rebreather mask or by BVM as patient condition permits • Premedicate as is appropriate: • Lidocaine • Versed / Valium • Atropine

20. Procedure • 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.

21. Procedure • 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

22. Procedure • 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.

23. Procedure • 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.

24. ***** • 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.