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.