CAP – Module 3
Endotracheal Intubation Rapid Sequence Intubation
CAP Module 3 – ET-RSI (GHEMS_April2015)
OBJECTIVES
 Review
Anatomy and Physiology
 Understand
the concept of Comprehensive
Airway Management
 Review
the concepts of RSI
 Review
the approach to the difficult airway
 Know
the protocols associated with airway
management
CAP Module 3 – ET-RSI (GHEMS_April2015)
CAP Module 3 – ET-RSI (GHEMS_April2015)
AIRWAY MANAGEMENT
 Airway
management involves multiple skills
 Knowledge
 Judgment
 Dexterity
 All
of these improve with field experience
CAP Module 3 – ET-RSI (GHEMS_April2015)
AIRWAY MANAGEMENT
Decision to Intubate
 Is
there a failure to maintain or protect the airway?
 Is
there a failure of ventilation or oxygenation?
 What
is the anticipated clinical course?
CAP Module 3 – ET-RSI (GHEMS_April2015)
AIRWAY MANAGEMENT
Decision to Intubate
Is there a failure to maintain or protect the airway?

Gag reflex vs. Swallowing

Immediately reversible conditions
 Opiod
overdose
 Cardiac
dysrhythmias
CAP Module 3 – ET-RSI (GHEMS_April2015)
AIRWAY MANAGEMENT
Decision to Intubate
Is there a failure of ventilation or oxygenation?

Asthma: oxygenates adequately, ventilatory failure

Pulmonary Edema: ventilates adequately, oxygenates
poorly
CAP Module 3 – ET-RSI (GHEMS_April2015)
AIRWAY MANAGEMENT
Decision to Intubate
What is the anticipated clinical course?

Multiple system trauma patient

Tricyclic antidepressant overdose

Neck injuries
ENDOTRACHEAL INTUBATION
Indications

Respiratory or cardiac arrest

Obtundation or unconsciousness without gag reflex

Risk of aspiration

Airway obstruction

Respiratory extremis secondary to disease or trauma
CAP Module 3 – ET-RSI (GHEMS_April2015)
ENDOTRACHEAL INTUBATION
Contraindications

Epiglottitis, unless airway obstruction imminent

Inability to identify airway landmarks
CAP Module 3 – ET-RSI (GHEMS_April2015)
ENDOTRACHEAL INTUBATION
Advantages

Isolates the trachea

Prevents gastric distention

Eliminates need for mask seal

Provides direct route for respiratory suctioning
CAP Module 3 – ET-RSI (GHEMS_April2015)
ENDOTRACHEAL INTUBATION
Disadvantages

Requires training and experience

Requires specialized equipment

Requires direct visualization of vocal cords

Bypasses upper airway’s functions of warming, filtering,
humidifying inhaled air
CAP Module 3 – ET-RSI (GHEMS_April2015)
A&P REVIEW
Upper airway

Nasopharynx

Oropharynx

Laryngopharynx

Larynx
CAP Module 3 – ET-RSI (GHEMS_April2015)
A&P REVIEW

Glottic structures

Glottic opening

Vocal cords

Cuneiform cartilage

Corniculate cartilage
CAP Module 3 – ET-RSI (GHEMS_April2015)
Together make up the
Arytenoid Cartilage
A&P REVIEW

Laryngeal landmarks

Thyroid cartilage

Cricothyroid
membrane

Cricoid membrane

Thyroid gland
CAP Module 3 – ET-RSI (GHEMS_April2015)
CRICOID PRESSURE

Also called Sellick’s maneuver

Posterior displacement of cricoid ring occludes
esophagus.

Helps prevent

Gastric insufflation

Passive regurgitation of vomitus in supine, obtunded, or
paralyzed patients
CAP Module 3 – ET-RSI (GHEMS_April2015)
CRICOID PRESSURE
Technique

Hold cricoid cartilage between thumb and index finger.

Apply posterior pressure.
CAP Module 3 – ET-RSI (GHEMS_April2015)
CRICOID PRESSURE

Before and After
CAP Module 3 – ET-RSI (GHEMS_April2015)
CRICOID PRESSURE VS. LARYNGEAL
MANIPULATION
 CP
may move the glottic opening
posteriorly, enhancing visualization of the
cords.
 If
goal is to move glottis into view, utilize
laryngeal manipulation, not CP.
 BURP
maneuver (backward, upward, and
rightward pressure on larynx)
 Much
more effective than CP at relocating
glottis to position of increased visibility
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI
Rapid Sequence Intubation (RSI)
The administration of a potent sedative (induction) agent
followed immediately by a rapidly acting neuromuscular
blocking agent (NMBA) in order to induce unconsciousness
and motor paralysis to facilitate endotracheal intubation
(ETI)
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI
RSI assumes the need for immediate airway control and
a full stomach with risk of aspiration

Maximizes your chances

Increases the risk
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI
Rapid Sequence Intubation

Preparation

Preoxygenation

Pretreatment

Paralysis with induction

Protection and positioning

Placement with proof

Postintubation management
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI: PREPARATION

Assess airway. Have plan ready for failed airway. Make
sure all present are familiar with it.

Induction agent and paralytic drawn
•
Labeled syringes
•
Contraindications to drugs reviewed

Preoxygenation of patient

Monitor Heart rate and SaO2
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI: PREOXYGENATION

Creates oxygen reservoir within blood and body tissues

Allows for several minutes of apnea without arterial
oxygen desaturation

Patient should be administered 100% oxygen for five
minutes before administration of NMBA.
CAP Module 3 – ET-RSI (GHEMS_April2015)
APNEA AND HYPOXIA
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI: PRETREATMENT
Pretreatment medications are
administered IV.

Lidocaine
(for reactive airways or
increased ICP)

Atropine
( For Children <8 years old)
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI: PARALYSIS WITH INDUCTION
Pre-Medication:

Propofol

Versed
Paralysis:

Succinylcholine
•
medications administered rapid IV push
•
Loss of consciousness and paralysis will occur rapidly
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI: PROTECTION AND POSITIONING
Cricoid pressure should be applied the moment loss of
consciousness is noted.

Maintained until ETT placement confirmed
RSI: PLACEMENT WITH PROOF

Patient's jaw should be
adequately flaccid within
45–60 seconds

Administration of NMBA
allows for optimal
laryngoscopy.

ETI performed

Confirm with ETCO2,
auscultation.
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI: PLACEMENT WITH PROOF

Do not rush intubation!


Laryngoscopy can be performed as long as SaO2
remains above 90%.


Monitor SaO2 .
May be minutes if patient is properly preoxygenated
Stop laryngoscopy and provide BVM ventilations with
cricoid pressure until SaO2 is back to prelaryngoscopy
level.
CAP Module 3 – ET-RSI (GHEMS_April2015)
RSI: POST-INTUBATION MANAGEMENT





Tube secured
Initiate ventilation
Cervical collar applied
Patient immobilized to
backboard
Post-intubation medications
 Propofol
 Versed
 Valium
 Vecuronium/Pancuronium prn
If Valium or Versed is used also use
Fentanyl 50 mcg
CAP Module 3 – ET-RSI (GHEMS_April2015)
Grays Harbor Emergency Medical Services
Medication Protocol
No. MED-360
Effective: August, 2004
Revised:
PARAMEDIC
PROPOFOL
Trade Names:
Diprivan
Class:
Therapeutic Action:
Mechanism of
Action:
Sedative-Hypnotic
Indications:
o
o
o
Induction
Sedation
Conscious Sedation
Contraindications:
o
Hypersensitivity to Propofol, Soy, Peanuts or Eggs
Adverse/Side
Affects:
o
o
o
o
o
o
o
o
o
Injection Site Pain
Involuntary Muscle movement
Nausea & Vomiting
Anaphylaxis (rare) – soy & peanut allergy
Respiratory Acidosis
Bradycardia
Hypertension
Hypotension
Torsades de Pointes – Responds well to MgSO4
Drug Interactions:
Dosage:
Adult: Sedation – Induction
50-100mg IV (1 – 2.5mg/kg) Dose varies
Adult: Sedation – Maintenance
10mg or 20mg incremental IV bolus doses
Peds: Sedation – Induction
(3 – 16yo & Healthy)
2.5 – 3.5mg/kg IV; as above
Dose Adjustments:
Administration:
Geriatrics, Weight, ETOH, etc – titrate
o
Use dedicated line
o
Dilute only with normal saline to a concentration not less than
2mg/ml
o
Maintain strict aseptic technique during handling
Monitoring:
Continuously; Hypotension; Apnea; Airway Obstruction; Oxygen
Desaturation
Onset:
Duration:
30-60 seconds
3 minutes
Pregnancy Category:
B
Grays Harbor Emergency Medical Services
Medication Protocol
*****
No. MED-280
Effective: August, 2004
Revised:
PARAMEDIC
MIDAZOLAM HCL
Trade Names:
Class:
Therapeutic Action:
Versed
Short-acting Benzodiazepine
Relieves apprehension and impairs memory during
cardioversion and endotracheal intubation.
Mechanism of Action:
Indications:





Contraindications:







Adverse/Side Affects:
Drug Interactions:
Premedication for:
Endotracheal Intubation
Cardioversion
Conscious Sedation
Excited delirium
Hypersensitivity to Midazolam
Glaucoma
Shock – Depressed Vital Signs
Coma
Overdose
Alcohol intoxication
Barbiturates; Narcotics; or other CNS depressants on
board

Cough

Oversedation

Pain at injection site

Blurred Vision

N/V

Hypotension

Fluctuating Vitals

Respiratory Depression or Arrest
Narcotics, Benzodiazepines, Barbiturates, or other CNS
depressants accentuate sedative effects
Dosage:
Adult:
1 – 5mg IV over 2 – 3 minutes. May be repeated in 1mg
increments; not to exceed 0.1mg/kg
Adult: Excited delirium
10mg IV
Peds:
0.1mg/kg
Onset:
Duration:
1 – 3 minutes IV
2 – 6 hours
Grays Harbor Emergency Medical Services
Medication Protocol
NOTE: DOSE SHOULD BE REDUCED BY 50% IN THE ELDERLY
No. MED-110
*****
Effective: August, 2004
Revised:
PARAMEDIC
DIAZEPAM
Trade Names:
Valium
Class:
Benzodiazepine
Therapeutic Action:
Suppresses seizure activity in motor cortex. CNS depressant and muscle
relaxant. Suppresses anxiety and tremors with DT’s, mild amnesic. Sedative
effects during cardioversion and TCP.
Mechanism of Action:
Binds to specific benzodiazepine receptors in the CNS, which inhibits neuronal
transmissions.
Indications:






Acute Anxiety and tremors in alcoholic delirium tremens.
Grand Mal seizures
Premedication for cardioversion, TCP and RSI
Acute Anxiety states and Cocaine toxicity
Severe back or muscle spasms
Excited delirium
Contraindications:





Hypersensitivity to Benzodiazepines
CNS depression secondary to head injuries or mind altering drugs,
Pregnancy (mother comes first)
Respiratory depressed patients
Shock
Patients with alcohol and depressant drugs on board.
Adverse/Side Affects:







Hypotension
Respiratory depression or arrest
Confusion
N/V
Coma
Periods of excitement
Reflex tachycardia.
Drug Interactions:
Potentiates effects of other CNS depressing medications. May react with other
medications in IV line. Barbiturates, Alcohol, and other narcotics will increase
effects of benzodiazepines.
Dosage:
Adult: Seizures
1-5mg IV, IM, or ET as needed. Adult: Anxiety
2-5mg IM, slow IV
Adult: Premedication
5-10mg slowly IV, IM or ET; 5-10 prior to TCP/Cardioversion or Succinylcholine
use.
Peds: Seizures
0.1 – 0.3mg/kg IV, IO, or ET (no faster than 1mg/min)
0.3 – 0.5mg/kg rectally q 10 – 15min total 3 doses
Onset:
IV: 1 – 5min IM: 15 – 30min, ET rapidly
Duration:
IV: 15min – 1 hour, IM: 15min – 1 hour, ET 15min – 1 hour
NOTE: DOSE SHOULD BE REDUCED BY 50% IN THE ELDERLY
Grays Harbor Emergency Medical Services
Medication Protocol
No. MED-380
Effective: August, 2004
Revised:
PARAMEDIC
SUCCINYLCHOLINE
Trade Names:
Class:
Therapeutic Action:
Mechanism of Action:
Indications:
Contraindications:
Adverse/Side Affects:
Drug Interactions:
Anectine
Depolarizing Neuromuscular Blocker (Paralytic)
Paralysis of Diaphragm and Skeletal muscles throughout the
body.
Binds with receptors at the motor end plate of skeletal,
muscle and the diaphragm thereby blocking acetylcholine
from attaching to the receptors. Because it binds to the
receptors instead of blocking them; muscle fasiculations
and some muscle contractions occur.
o
To facilitate intubation of patients which have an
intact gag reflex
o
Termination of Laryngospasms
o
Penetrating eye injuries (Succ’s ↑ intraocular
pressure)
o
Unlikely to have a successful intubation
o
Neuromuscular Disease (Myasthenia Gravis)
o
Absence of Surgical Airway Skills
o
Narrow Angle Glaucoma (Succ’s ↑ intraocular
pressure)
o
Severe Uncontrolled Hypertension
o
Recent Trauma Surgery
o
Major unhealed burns <24 hours old
o
Hyperkalemia
o
Muscle fasiculations
o
Hypersalivation (atropine?)
o
Bradycardia (atropine?)
o
Malignant Hyperpyrexia (rare, muscle rigidity,
tachycardia, hypertension)
o
Trismus (locking of jaw & teeth clenching) Don’t give
more Anectine.
o
o
o
Oxytocin, Beta-blockers, Procainamide, Lidocaine,
Magnesium salts and Organophosphates may
potentiate effects.
Diazepam may reduce duration of action
Digoxin may cause dysrhythmias
Dosage:
Adult/Ped:
1 – 2mg/kg rapid IV
Onset:
Duration:
Less than 1 minute
4 – 6 minutes
Grays Harbor Emergency Medical Services
Medication Protocol
No. MED-430
Effective: August, 2004
Revised:
PARAMEDIC
VECURONIUM
Trade Names:
Class:
Therapeutic Action:
Mechanism of Action:
Norcuron
Non-Depolarizing Neuromuscular Blocker
Paralysis of diaphragmatic and skeletal muscles
throughout the body.
A non-depolarizing neuromuscular blocker (NMB), blocks
the receptor sites for Acetylcholine on the motor end
plate (MEP), preventing stimulation of the muscle fibers.
Indications:
Intubated patients that are:
o
Bucking or fighting the endotracheal tube
o
Attempting to Extubate themselves
o
At risk of harming Paramedical Personnel
o
Trismus (locking of jaw and teeth clenching)
Contraindications:
o
o
o
o
Myasthenia Gravis
Newborns
Patients with Unsecured Airways
Patients which require a neuro examination upon
arrival to ER
Adverse/Side Affects:
o
o
o
o
Apnea
Hypoxia
Hypercarbia
Profound Weakness
Drug Interactions:
Increased neuromuscular blockade:
Clindamycin, Lincomycin, Quinidine, Polymyxin
Antibiotics, Local Anesthetics, Lithium, Narcotics,
Thiazides
Dysrhythmias:
Theophylline
Dosage:
Adult/Children >9y/o:
0.1mg/kg IV
Maintenance – 0.01 – 0.015 mg/kg
Onset:
Duration:
3 – 5 minutes
45 minutes to 1 hour
Grays Harbor Emergency Medical Services
Medication Protocol
No. MED-345
Effective: August, 2004
Revised:
PARAMEDIC
** ALTERNATIVE MEDICATION **
PANCURONIUM BROMIDE
Trade Names:
Class:
Therapeutic Action:
Mechanism of Action:
Pavulon
Nondepolarizing, neuromuscular blocking agent
Indications:

Intubated patients requiring the need to be paralyzed for
prolonged periods of time.
Contraindications:



Hypersensitivity to Pancuronium or bromide products
Patients with Unsecured Airways
Patients which require a Neuro examination upon arrival to ER.
Adverse/Side Affects:







Increased saliviation
Hypertension
Tachyarrhythtmia
Prolonged neuromuscular block
Apnea
Bronchospasm (rare)
Respiratory Failure
Drug Interactions:
Prior administration of succinylcholine may enhance the neuromuscular
blocking effect of Pancuronium bromide and increase its duration of
action. If succinylcholine is used before Pancuronium bromide, the
administration of Pancuronium bromide should be delayed until the
patient starts recovering from succinylcholine-induced neuromuscular
blockade
Dosage:
Adult: 0.06 – 0.1 mg/kg IV
.
Peds: 0.04 – 0.1 mg/kg IV
Onset:
Approximately 4 minutes
Duration:
89 – 161 minutes
o Doubled in patients with cirrhosis, biliary obstruction and renal failure
Nondepolarizing, neuromuscular blocking agent belonging to the
curaroform class of drugs. Its activity leads to neuromuscular blockage
by competing for chollnergic receptors at the motor end-plate.