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Rapid Sequence Intubation: Dr. Zulkarnain, Span

This document summarizes the process of rapid sequence intubation (RSI). RSI involves using medications to facilitate endotracheal intubation in a controlled manner to secure the airway without aspiration. It discusses the indications for RSI, the 6 P's of RSI preparation process (preparation, preoxygenation, pretreatment, paralysis, placement of the tube, and post-intubation management), common medications used, and management after intubation. The goal of RSI is to intubate the patient safely and quickly to protect their airway.

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Nisa Apriani
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83 views26 pages

Rapid Sequence Intubation: Dr. Zulkarnain, Span

This document summarizes the process of rapid sequence intubation (RSI). RSI involves using medications to facilitate endotracheal intubation in a controlled manner to secure the airway without aspiration. It discusses the indications for RSI, the 6 P's of RSI preparation process (preparation, preoxygenation, pretreatment, paralysis, placement of the tube, and post-intubation management), common medications used, and management after intubation. The goal of RSI is to intubate the patient safely and quickly to protect their airway.

Uploaded by

Nisa Apriani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Rapid Sequence

Intubation

dr. Zulkarnain, SpAn


Rapid Sequence Intubation

 RSI
 The use of medication to facilitate passing the
endotracheal tube
 Analgesics
 Sedatives
 Paralytics
 CONTROLLED procedure
 Will take several minutes to accomplish
 Requires a team effort
 The ultimate goal is to secure an airway
without having the patient vomit and aspirate.
Indications for RSI
 Impending airway obstruction
 Facial fractures…no excessive oral bleeding
 Facial burns…inhalation injury
 Expanding retropharyngeal hematoma

 Excessive work of breathing


 Example…the exhausted asthmatic
 Shock
 GCS <8
 Persistent hypoxia (<90%)
6 P's of RSI

 Preparation
 Preoxygenation
 Pretreatment
 Paralysis (with induction)
 Placement of the tube
 Post intubation management
Preparation

 Oxygen Source  Pulse oximeter


 Suction Equipment  End-tidal CO²
 Endotracheal tubes monitor
 Bag-valve-mask  Temperature probe
device (LONG TERM)
 Glidescope  Alternative airway
 Cardiac Monitor equipment-laryngeal
mask airway or jet
ventilator or crich
tray
Preparation

 Assign roles and responsibilities


 Leader
 Intubationist
 Cricoid pressure
 Monitoring
 Medications
 Documentation
2. Preoxygenate

 3-5 minutes with 100% O2 bag mask to


ensure adequate oxygen reservoir in
lungs during apnea
 Assure age appropriate fitting mask
3. Pre-treatment
 Laryngoscopy causes stimulation of afferent
receptors in the posterior pharynx,
hypopharynx and larynx.
 Reflexes can cause:
– Increased intracranial pressure (ICP)
– Stimulation of upper & lower respiratory tract
increasing airway resistance.
– Stimulation of autonomic nervous system,
with increase heart rate and BP (vagal
stimulation cause decrease in pediatric!)
Pre-treatment

 Attenuate (weaken) normal physiologic &


pathophysiological reflex responses
caused by airway manipulation during
laryngoscope and insertion of an
endotracheal tube.
- Lidocaine
- Atropine
- Defasiculating agent
Pre-treatment meds

 Atropine – Treats brady response to


SUX, and in young children.
 Lidocaine – Helps decrease ICP
associated with intubation.
 Vecuronium (defasiculationg dose)-
keeps muscles from fasiculating
(twitching) when using “Succs”
4. Paralysis (with induction)

 Check patency of line first!


 Make sure everyone is ready
 Give IV pushes rapidly and flush
 Anesthesia before paralysis!
 *Induction agent is followed immediately
by the paralytic without waiting to see if
ventilation can be maintained
 Hallmark of RSI
Anesthesia

 Etomidate
 Short acting sedative
hypnotic
 Dose=0.3 mg/kg
 Induction time= 5-10
min.
 *Myoclonus
Ketamine

 IM or IV  Glazed eyes &


 Dissociative nystagmus
anesthesia  Watch for agitated
 Dose = 1-2 mg/kg recovery
(IV)/ 4-10mg/kg IM  *Increased BP,
 Lasts approx. 30” HR,tonic/clonic,N/V,
hypersalivation
Anesthesia

 Versed
 Benzodiazepine,
 Sedative
 1-2 mg IV
 Onset 1.5 min. to 2H
 *Hypotension
Anesthesia

 Fentanyl
 Narcotic analgesic
 50-100 mcg/kg
 Lasts 30 min.
 *Resp. depression
Propofol (Diprivan)

 Induction agent
 Standard dose: 2
mg/kg
 Rapid onset, short
duration
 Considerations:
*Hypotension,apnea
Paralytic (Neuromuscular
block)
 VECURONIUM
 Skeletal Muscle
Relaxer
 0.1 MG/KG
IV(PARALYZING
DOSE)
 Lasts 25 to 45 min.
Paralytic

 SUCCINYLCHOLINE  Side effects:


 Neuromuscular  Fasciculations,
blocking agent muscle pain,rhabdo,
 Dose: 1 mg/kg hyper K, brady, vent.
 Duration: 5 min. Dysthythmias
 Malignant
Hyperthermia
Paralytic
Contraindications
 – Personal or family
history of malignant
 hyperthermia
 – Significant, verified,
hyperkalemia is an
 absolute contraindication
 – End-stage renal
disease / dialysis
dependent
 patients with unknown
potassium level
5. Placement of Tube

 Position patient
• Do not bag unless SpO2 < 90%
• Sellick’s Maneuver (Cricoid pressure)
Placement of tube
Placement and Proof

 Confirm tube
placement
 – ETCO2
 – Bilateral breath
sounds
 – Absent epigastric
sounds
Failed attempt

What if the intubation attempt is not


successful?
 1st step = bag/mask ventilation for
support
Rescue Maneuvers
 – The first rescue from failed intubation is
bagging
 – The first rescue from failed bagging is better
bagging
6. Post-intubation
Management
 Secure tube
 ETCO2
 Chest x-ray
 Long acting sedation (+/- paralysis)
 – Midazolam 0.2mg/kg
 – Propofol 25-50μg/kg/min
 Establish ventilator parameters
6P’s RSI Summary

• Preparation (zero – 10 minutes)


• Preoxygenation (zero – 5 minutes)
• Pretreatment (zero – 3 minutes)
• Paralysis with induction (time zero)
• Positioning (zero + 30 seconds)
• Placement (zero + 45 seconds)
• Post-tube management (zero + 90
seconds)
Questions?

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