Intro to:
Objectives Define RSI Identify the Indicators for using RSI Identify the relative contraindications and
disadvantages of RSI Discuss the different roles in the RSI process Review the crucial 7 P’s of RSI Review the medications used during RSI Review a difficult airway and identify
alternative tools and techniques
What is RSI?
Why RSI?
Respiratory failure Inability to protect own airway Impending or potential airway
compromise GCS less than 8 Intractable seizures
Relative contraindications to RSI Airway obstruction Distorted anatomy Major facial or laryngeal trauma Angioedema
Disadvantages of RSI
Hypoxia if unable to complete intubation RSI blocks the patient’s involuntary
reflexes and muscle tone in the oropharynx and larynx
Adverse medication reactions Masks underlying symptoms Requires considerable amount of
training and recurrent training
The benefit of obtaining airway control must always be weighed against the risk of complications in these patients.
You are taking a breathing patient and making them APNEIC
RSI Equipment Airway equipment (ET, syringe, stylette,
etc) Oxygen Suction equipment Ecg monitor IV equipment SaO2 monitor Capnography RSI meds
It’s a team effort!
Skilled intubator Timekeeper/scribe Vital sign monitor Medication administrator Assistant
Before you get started…. In the ideal world Get medical history Obtain baseline neuro exam Check all your equipment Confirm pt. weight
7 Essential P’s of RSI
Preparation Pre-oxygenate Pre-medicate Paralysis and Induction Protection Placement of the tube Post Intubation management
Preparation
Prepare all equipment including ETT, suction, pulse oximeter, IV and monitor
Position patient in sniff position if C-spine immobilization is not indicated.
Pre-Oxygenate
Pre-oxygenate with 100% oxygen via NRB for at least 3 min. or 8 vital capacity breaths with 100% oxygen.
If ventilatory assistance is necessary with BVM, be gentle and apply cricoid pressure.
Do you predict a difficult airway? Short neck or no neck Small mandible Obesity Facial/maxillary trauma Edema or infection Degenerative spinal disease
What does a difficult airway mean to you?
Be prepared!
Have plan B, C, and D if intubation fails.
Tools for a difficult airway Have one ETT tube size smaller &
bigger available ETTI (Bougie, Eshman, etc) Back up devices (Combitube, King
airway) Surgical airway kit
Are you ready?
What drugs do we use?
OxygenVentilate while preparing for RSI
Lidocaine? Atropine? Versed Etomidate Succinylcholine Vecuronium
Procedure Pre-oxygenate – (NOT hyperventilate) for 2 – 3
min. Assemble equipment Proximal IV preferred Connect pt. To monitor Lidocaine (TBI) Atropine (children < 10) Versed Etomidate Succinylcholine Sellick maneuver
Procedure, cont. Stop ventilations Observe for fasiculations Intubate
If unable to ventilate in 20 sec. , stop and ventilate for 30 – 60 sec.
May give second dose of Sux (1 – 1.5 time initial doseIf bradycardia occurs, give Atropine and
hyperventilate Confirm intubation Attach Easy Cap or capnography device Administer Vecuronium MONITOR PATIENT
Protect the Patient
Maintain cervical stabilization prn Maintain cricoid pressure until tube
placement is confirmed and secured. Constant vigilance of monitoring
oxygenation
Whose tube is it?
The most experienced medic! If unable to intubate within 20 seconds
or SaO2 drops below 92%, STOP and ventilate with BVM
Confirm placement Release cricoid pressure
How did you confirm the tube? Gold standard (visualized tube passing
through the cords Capnography Mist in the tube Bilateral breath sounds
Recheck tube placement after every patient move, if airway resistance occurs or increases, hear rate decreases, or O2 desaturation occurs
Post medication
Continue paralysis with Vecuronium Continue sedation with Versed Consider pain control
What if you can’t get the tube in?? Provide 100% oxygen with BVM Consider back up device Consider surgical airway
All neuromuscular Blocking Agents: Work by blocking the natural
transmission of nerve impulses to skeletal muscles.
No direct effect on Heart, Digestive system, Brain, Pupillary response, Smooth Muscle or other organ systems
No effect on mentation or pain perception!
No direct effect on seizure activity.
Remember….
If performed correctly, RSI will take between 7 – 10 minutes.
You are taking a breathing patient and making them apneic.
Always be prepared and know your RSI protocol.