By:

Margaret D. EstevezRapid Sequence Intubation

Definitions

Rapid Sequence Intubation is an important technique by sedating and paralyzing the patient allowing for easier intubation.Sellicks Maneuver - A method of preventing regurgitation of an anesthetized patient during endotracheal intubation by applying pressure to the cricoid cartilage.ETT endotracheal tubeER - Emergency RoomDifficult Airway a clinical situation in which a conventionally trained clinical physician or anesthesiologist experiences difficulty with mask ventilation, tracheal intubation or bothEDD esophageal detector deviceBVM Bag Valve MaskLMA - laryngeal mask airway

EDDBVM

Laryngeal Mask Airway

ObjectivesTo standardized Rapid Sequence Intubation in ERTo ensure optimal care for patients need airway managementThis policy applies to all Rapid Sequence Intubation in the department of Emergency Room

Hospital Policies on RSI

RSI should be performed by physicians possessing training, knowledge and experience in the techniques and pharmacological agents used in RSI.Neuromuscular blocking agents and appropriate induction agents should be used in the ER.Preparation of appropriate medication and appropriate patient, bed and intubator positions should take place before performing RSI.Airway assessment for difficulty should be done before RSI.Difficult airway cart and crash carts should be available in the area where the RSI will be performed.

The Anesthesiologist on-call should be notified for all anticipated difficult airway and should be consulted for all failed intubationDifficult airway algorithm should be followed for anticipated difficult airwayAnticipation of complication and immediate response should take place for all RSIAll difficulties encountered during laryngoscope view should be documented on the ED sheet.RSI audit form should be filled by the nurse in charge of the patient and signed by the team leader in charge of the shift.Quality review and patient monitoring should be addressed and audited on a regular basis by ER Quality Management using the Quality Audit Form

IndicationsFailure to maintain airway tone Swelling of upper airway as in anaphylaxis or infection, burnsHead, facial or neck trauma with oropharyngeal bleeding or hematomaDecreased consciousness and loss of airway reflexes Failure to protect airway against aspiration - Decreased consciousness that leads to regurgitation of vomit, secretions, or blood Failure to ventilate End result of failure to maintain and protect airwayProlonged respiratory effort that results in fatigue or failure, as in status asthmaticus or severe COPD, CHF

Failure to oxygenate (ie, transport oxygen to pulmonary capillary blood) End result of failure to maintain and protect airway or failure to ventilateDiffuse pulmonary edemaAcute respiratory distress syndromeLarge pneumonia or air-space diseasePulmonary embolismCyanide toxicity, carbon monoxide toxicity, methemoglobinemia

5.Anticipated clinical course or deterioration (eg, need for situation control, tests, procedures) Uncooperative trauma patient with life-threatening injuries who needs procedures (eg, chest tube) or immediate CT scanningStab wound to neck with expanding hematomaSeptic shock with high minute-ventilation and poor peripheral perfusionCVA, Intracranial hemorrhage with altered mental status and need for close blood pressure controlCervical spine fracture with concern for edema and loss of airway patency

ContraindicationsAbsolute Total upper airway obstruction, which requires a surgical airwayTotal loss of facial/oropharyngeal landmarks, which requires a surgical airwayRelative Anticipated "difficult" airway, in which endotracheal intubation may be unsuccessful, resulting in reliance on successful bag-valve-mask (BVM) ventilation to keep an unconscious patient alive The "crash" airway, in which the patient is in an arrest situation, unconscious and apneic.

EquipmentLaryngoscopeLaryngoscope handle, No. 3 Macintosh (curved) blade, and No. 3 Miller (straight) blade. Endotracheal (ET) tubeStyletSyringe, 10 mL (to inflate ET tube balloon)Suction catheter (eg, Yankauer)Carbon dioxide detector (eg, Easycap)Oral and nasal airwaysAmbu bag and mask attached to oxygen sourceAssistant for cricoid pressure

Intubation EquipmentLaryngoscope handle, No. 3 Macintosh (curved) blade, and No. 3 Miller (straight) blade.

Laryngoscope handles with an assortment of Miller blades (large adult, small adult, child, infant and newborn)

Laryngoscope handle with an assortment of Macintosh blades (large adult, small adult, child, infant and newborn)

A Carlens double-lumen endotracheal tube, used for thoracic surgical operations such as VATS lobectomy

An endotracheal tube stylet, useful in facilitating orotracheal intubation

A cuffed endotracheal tube, constructed of polyvinyl chloride

Positioning

In the neutral position, the oral, pharyngeal, and laryngeal axes are not aligned to permit adequate visualization of the glottic opening.Place the patient in the sniffing position for adequate visualization; flex the neck and extend the head. This position helps to align the axes and facilitates visualization of the glottic opening. Recent studies have shown that simple head extension alone (without neck flexion) was as effective as the sniffing position in facilitating endotracheal intubation.

Proper alignment of the axes for tracheal intubation.

THE 7 Ps of RSI

PreparationPre oxygenationPretreatmentParalysisPlacementPlacement and ProofPostintubation Management

PreparationContinuous ECG, SPO2 and BP monitoringFunctional laryngoscope, and BVM with high flow oxygenEndotracheal tubes, stylet and a 10cc syringeAlternate airway LMA and crycothyrotomy equipment availableAll the medications should be drawn up and labeledAn assessment should be made for difficult intubationThe suction should be on and readyTube confirmation equipment should be availableAll Intravenous access should be secured and finally,The bed should be positioned at the level of the intubator built

Difficult Airway/Intubation Assessment

L.E.M.O.N.

L: Look externally

E: Evaluate the 3-3-2 ruleThe chance for success is increased if the patient is able to insert 3 of his or her own fingers between the teeth, can accommodate 3 finger breadths between the hyoid bone and the mentum and is able to fit 2 finger breadths between the hyoid bone and the thyroid cartilage.

Hyomental distance (3 finger breadths)

Thyrohyoid distance (2 finger breadths)

M: Mallampati classification

The Mallampati assessment is ideally performed when the patient is seated with the mouth open and the tongue protruding without phonating. A crude assessment can be performed with the patient in the supine position to gain an appreciation of the size of the mouth opening and the likelihood that the tongue and oropharynx may be factors in successful intubation.

Mallampati classification

O: Obstruction

Three signs of upper airway obstruction are:difficulty swallowing secretions (secondary to pain or obstruction)stridor (an ominous sign which occurs when < 10% of normal caliber of airway circumference is clear)a muffled (hot-potato) voice

N: Neck mobility

The inability to move the neck affects optimal visualization of the glottis during direct laryngoscopy. 1. Cervical spine immobilization in trauma (with a C-collar) can compromise normal mobility.2. Due to medical conditions such as ankylosing spondylitis or rheumatoid arthritis.

Preoxygenation

Administer 100% oxygen for 5 minutes for unconscious patients or 8 vital capacity deep breaths on 100% oxygen for conscious patients.

Use the least assistance necessary to obtain good oxygen saturation and adequate preoxygenation.High-flow oxygen via nonrebreather mask may be appropriate for a patient with good respiratory effort.High-flow oxygen via well-fitting bag-valve-mask (BVM) without additional positive pressure (ie, squeezing the bag) may be needed for those with more respiratory compromise.High-flow oxygen via BVM with positive pressure assistance (squeezing the bag) is used only when necessary.

Pretreatment

Consider administration of drugs to mitigate the adverse effects associated with intubation.Pretreatment medications are typically administered 2-3 minutes prior to induction and paralysis.LOAD (ie, Lidocaine, Opioid analgesic, Atropine, Defasciculating agents).

Pretreatment Medications

MedicationDoseIndicationLidocaine1.5 mg/kg IVTo decrease bronchospasm and decrease intracranial pressureFentanyl3g/kg over 1 minCAD, ICH, raised ICP, Aortic Dissection, High BPAtropine0.02 mg/kg (min 0.01 mg, max 0.5 mg)To prevent bradycardia in children 10 years old who are receiving succinylcholine for intubation

Defasciculating Agents

Decreases muscle fasiculations caused by the depolarizing agents (succinylcholine)Attenuates rise in intracranial pressureAgents used are the non-depolarizing blocking agents (vecuronium, pancuronium etc.) usually 1/10 of standard dose

Paralysis with Induction

INDUCTION AGENTSAdminister a rapidly-acting induction agent to produce loss of consciousness.

NEUROMUSCULAR BLOCKING AGENTSAdminister a neuromuscular blocking agent immediately after the induction agent.Muscle relaxantThese medications should be administered as an intravenous push.

Induction Agents

SEDATIVESIV DOSE (mg/kg)ONSET (min)EFFECT ON BPEFFECT ON ICPMidazolam0.2-0.41-2MinimalMinimalEthomidate0.2-0.4

Paralytic Agents

AgentDose (m/g)Onset (min)Duration (min)Succynyl choline1.513-5Pancuronium0.12-540-60Vecurunium0.1330-350.25160-120Atracarium0.5325-35Mivacarium0.152-315-20Rocuronium1.01-1.530-110

ProtectionHold the Sellicks maneuver from pretreatment through proof of proper placement.

Placement with proof

Place the ETTConfirm tube placement with at least three of any of the following methods:Visualize the ET tube passing through the vocal cords

Observe color change on a qualitative end-tidal carbon dioxide device.Use the 5-point auscultation method: Listen over each lateral lung field, the left axilla, and the left supraclavicular region for good breath sounds. No air movement should occur over the stomach. EDD/Bulb AspirationOxygen saturations maintained >95% at 1 minute and 5 minutesChest X-Ray

Post Intubation Management

After the preceding procedures have been performed,the following should be observed:

First, secure the ET tube into place.Discontinue attempt and ventilate with 100% oxygen if:Thirty seconds has passed and/or oxygen saturation has fallen below 91%; andIf the patient becomes a bradycardic

3.If intubation is unsuccessful, continue cricoids pressure and provide BVM ventilation until the paralytic agent wears off and consider the use of LMA and failed intubation algorithmAdminister appropriate analgesic and sedative agents for patient comfort, to decrease O2 demand, and to decrease ICP.Maintain continuous ETCo2 monitoringContinue sedation and paralysis as indicatedMonitor the patients response, including vital signs, arterial blood gas values, cardiac monitor and arterial oxygen saturation.

Walls Difficult Airway Algorithm

Complications of RSIEsophageal intubationRight mainstem intubationPneumothoraxDental traumaPostintubation pneumoniaVocal cord avulsionFailure to intubateHypotensionAspirationIncrease ICP

Quality Audit FormPatient ID:Team Leader:Age:Date/Time:Diagnosis:Indication of RSI:Patient Estimated Weight: _____ kg

Drug UsedDoseTime Given1234

Methods Use for confirmation:YesNoBreath sounds over lungs, none gastricEnd-tidal CO2 color changeBulb aspirator quickly inflatesO2 saturation >95% at 30 sec, 1 min, 5minsChest X-ray requested post intubation:Chest X-ray seen by: ___________ MDComplications: (Anytime during or post RSI)Yes NoActions takenDesaturation (

References:

1. http://emedicine. medscape.com/article/80222-overview#a032. http://en.wikipedia.org/wiki/Rapid_sequence_induction3.http://web.nmsu.edu/~lleeper/pages/Voice/moreno/equipment_picture_gallery.htm4. https://ezcompetency.com/modules/4.php

-End- Thank you!

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