Rapid Sequence Induction
CPT James Rice, PA-C
Program Manager
Tactical Combat Medical Care
References
Emergency Medicine, A
Comprehensive Study Guide,
Tintinalli, 6th ed., McGraw-Hill, 2004
Emergency War Surgery, Third
United States Revision, Chapter 9,
Borden Institue, Walter Reed Army
Medical Center
Objectives
 Identify the difference between a “crash”
endotracheal intubation and RSI with
endotracheal intubation.
 Identify the indications for RSI
 Discuss concepts in preparing your trauma
team for RSI
 Identify the equipment and medication
required for RSI
 Discuss the steps in performing RSI
“Crash” vs. RSI
“Crash” endotracheal intubation
– No use of medication to facilitate the
procedure
– The casualty is unconscious,
unresponsive and has no gag reflex.
– EMERGENCY…can be a flail!
“Crash” vs. RSI
 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 casualty 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
 Remember that RSI is a team effort
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Intubationist
IV/med person
Suction/ET tube person
Cricoid pressure
“Fish hook”
O2 Sat person
 You should have all of these jobs identified
and rehearse, rehearse, rehearse!!
Preparation
 Always have a back-up airway
intervention!!!
– After 2 attempts at passing the tube…you
probably aren’t going to get it
– Surgical cric is an excellent option
 Have a cric kit ready
 How are you going to ventilate the casualty
once you have the airway secured?
– Ventilator?
– Medic?
– Non-medic?
Preparation
 Develop RSI kits in the pre-deployment prep
– These items need to be co-located and easy to get to
 Meds
 Laryngoscope/blades/batteries/bulbs
– Need to be checked daily
 Suction…with rigid suction tip
– Needs to be checked daily
 ET Tubes/stylets/syringe
 Tape (with tongue blade)
 “J”-tube
 Ventilator if you have it
– Make sure you have all the components and check it
daily
 O2
Required Equipment
 Laryngoscope handle
– Recommend the pediatric handle…smaller,
lighter
 Laryngoscope blades
– Several sizes
 Macintosh vs. Miller is personal preference
 Batteries…take a bunch
 Laryngoscope blade bulbs…take a bunch
Required Equipment
ET tubes
– Various sizes
– Don’t forget some pedi sizes (no cuffs!)
ET tube stylets
10cc syringe
3 inch tape
– Wrap it over a tongue blade
Required Equipment
Suction
– Absolutely required!!
Suction catheter
– Keep it with the suction apparatus
“J”-tube
– Prevent the casualty from biting the tube
Oral-Gastric tube
Required Equipment
 O2 sat monitor
 Cardiac monitor
– Nice to have
 AMBU bag
– Can hook up the O2 and use it as a mask
 IV kit
 Portable Ventilator
– Nice to have
 Surgical cric kit
Required Medication
Narcotic
Amnestic, Anxiolytic
Sedative
Paralytic(s)
Required Medication
 Narcotic
– Remember, the paralyzed casualty will still feel
pain!
– Morphine 5-10mg load and then titrate at 2mg
every 5 min to effect
 Readily available
– Fentanyl?
 Effective with virtually no CV effects
 Currently recommended, but not readily available in
SKO
– Should we have Narcan readily available?
Required Medication
 Anxiolytic/Amnestic
– Versed 5mg slow IV push
 Good amnestic effect
 Readily available
 May cause hypotension in the “shocky” casualty
 Sedative
– Etomidate 0.3mg/kg IV
 Good sedative with good side effects profile
– The most common sedative in the ER setting
 Does not require refrigeration
 Is NOT in your SKO currently
Required Medication
 Lidocaine
– 1mg/kg IV
– Blunt the rise in ICP associated with intubation
 Recommended in the head trauma casualty, although
no data to support this effect
 Atropine
– 0.02mg/kg IV (min dose 0.10mg)
 Children
– Blunts the reflex bradycardia and helps dry up secretions
Required Medication
 Paralytics
– Succinylcholine
 1.0mg/kg IV
 Depolarizing
– Onset in 30-60 seconds
– 5-10 minute duration
 Can cause fasciculations, bradycardia, elevated ICP,
elevated intragastirc pressure and malignant
hyperthermia
 Requires refrigeration…possibly being remanufactured in an unconstituted form
 Not in your SKO
Required Medication
 Vecuronium
– 0.1mg/kg IV (paralytic dose)
– Non-depolarizing
 2-3 minute onset
 30-40 minute duration
 A dose of 0.01mg/kg is a very effective way to prevent
the fasciculations associated with succinylcholine
– Comes in an unconstituted form…does not
require refrigeration
– Not in your SKO
Required Medication
 O2
– Understand you don’t have a lot
 Be conservative in regard to using your oxygen for the
medical emergency or trauma patient who is NOT
hypoxic
– Attach it up to your AMBU bag, then use the
AMBU bag as a face mask during the set
up/prep and pre-medication phases
– Applying PPV is not necessary and not
recommended unless the casualty isn’t breathing
Required Medication
NS
– Often overlooked by the non-nurse
– Required to flush the IV site after
administering IV push meds
– Simply have 15cc of NS in a syringe and
flush the IV site with 5cc after
administering the IV med
RSI Sequence
Set-Up/Preparation-key!!!
– Gather your team and ensure everyone
understands their job!
– Get at the head of the bed
Start directing traffic-KEEP CALM!!
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Gather your RSI kit
Preoxygenate
Reconstitute meds/draw up NS in a 15cc syringe
Ensure a patent IV site
Attach pulse oximeter
RSI Sequence
Set-Up/Preparation-key!!!
– Re-test your laryngoscope (should have
been tested already…)
– Test and set up your ET tube
– Have suction VERY CLOSE and turned
on with suction catheter attached
– Optimize the casualties head/neck
position
RSI Sequence
Pre-medication Phase
– Morphine
– Versed
– Lidocaine
– Atropine
RSI Sequence
Pre-medication Phase
– Defasciculation (optional)
Vecuronium 0.01mg/kg
RSI Sequence
 Cricoid pressure (Sellick Maneuver)
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Prevents aspiration
Helps bring the cords into view
Avoid compressing the carotids
Hold steady firm pressure until the intubation
is complete, the cuff is inflated and you have
confirmed tube placement!!!
 Bad form to allow the casualty to aspirate when we are
doing an RSI to prevent aspiration…
RSI Sequence
Sedate
– Etomidate
Wait about a minute, you should be able to
appreciate the sedative effect
RSI Sequence
Paralytic
– Succinylcholine
You should note paralysis within 60 seconds
– Vecuronium
You should note paralysis in 2-3 minutes
RSI Sequence
Once you note paralysis…Intubate
– Once you get eyes on the cords…don’t
take them off!
– You want to visualize the tube passing
between the cords
– Ensure someone places the tube into
your hand
– You WILL have to use the suction…keep
it close
RSI Sequence
PEARLS during the intubation
– Ensure continuous pulse oximetry
If you are having difficulty passing the tube
and the pulse ox reading falls to the mideighties…stop the procedure and begin
ventilating the casualty to a better state of
oxygenation… and then try again
– If you can’t successfully intubate after 2
attempts…stop and do a surgical cric
RSI Sequence
 Tube verification
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Visualized the tube passing between the cords
Auscultate lung sounds bilaterally with ventilation
Fog in the tube with exhalation
Palpate the tube within the trachea (possibly)
Casualties oxygenation has improved or is
maintained in the mid to upper 90’s
– CO2 detector attached to the tube (if you have it)
– Chest x-ray (if you are at level II)
Post Intubation
 The casualty needs to be ventilated
– That can be for a prolonged period of time
 Medic?
 Non-medic?
 Ventilator?
 Secure the tube
 A “J”-tube may be inserted
– Prevent biting of the tube
 An oral gastric tube should be inserted
– Decompress the stomach
Post Intubation
Ventilation
– Medic or non-medic
12-20 breaths per minute
– Disconnect the O2 and re-evaluate after several
minutes…you have limited O2 assets
Watch the pulse ox
Protect the tube
Post Intubation
 Ventilator
– Basic settings
 Tidal volume 10cc/kg
– Healthy lungs
 Resp rate 12-16/min
 PEEP of 5cm
 O2 100% (if you have an abundance)
– These are start points, you do not have the
ability to track ABG’s and fine tune your settings
 Keep it simple and leave that to the folks at Levels
III/IV
Post Intubation
 Keep them sedated and paralyzed
– If the Succinylcholine wears off…it will in about 5
minutes, the casualty may start to fight the
tube/ventilation
 Consider giving or maintaining the casualty on
Vecuronium…don’t forget giving some more
Morphine and Versed
– This will keep them paralyzed/sedated throughout the
evac system
 Would you like to be paralyzed without
sedation/analgesia?
– You should not consider extubating the casualty
at levels I/II…leave that to the folks with more
ICU experience/equipment and support.
Summary
RSI is a controlled procedure
RSI requires a team effort
Pre-planning and prep is absolutely
key
– Rehearse, rehearse, rehearse!!!
Medication options
Steps in performing RSI
Post intubation concepts
Questions??