RSI

[RSI Calculator]
P's of RSI
Predictor or difficult airway: (MOLES/Mallampati score)

Predictor of difficult BVM & Circulation:
  - NEVER paralyze pt. you think you can't intubate OR ventilate

Preparation:

  • ET tube
  • Ck laryngoscope
  • 2 blades ready
  • O2 & BVM connected
  • Suction
  • Drugs

Pre-Oxygenate: (2 min. on 100% @ 15 L/min using non-rebreather)

  • use 15L/min NC during intubation -- improves oxygenation during intubation process.

Pretreatment: (LOAD)

  • Lidocaine 1.5 mg/kg (to blunt ICP rise & ↓ bronchospasm in asthma)
  • Opiate (fentanyl 2-4 mcg/kg to blunt physio/CV response to intubation)
  • Atropine 0.02 mg/kg IV (in child to prevent potential lethal bradycardia/asystole)
  • Defasciculation
     

Put to sleep:

Agent Dose Induc. Dura-tion Benefits Caveats
Etomidate 0.3 mg/kg IV <1 min 10-20 min ICP Myoclonic jerking or seizures and vomiting in awake patients
Intraocular pressure No analgesia
Neutral BP Cortisol
Propofol 0.5-1.5 mg/kg IV 20-40s 8-15 min Anti-emetic Apnea
Anticon-vulsant BP
ICP No analgesia
Ketamine 1-2 mg/kg IV 1 min 10-20 min Broncho-dilator Secretions
"Dissociative" amnesia BP, ICP
Analgesia Emergence phenomenon
Fentanyl 2-3 mcg/kg IV < 60s 30-90 min Low risk of causing BP
- Reverse w/ Narcan
-
ICP
Myoclonus in high dose.
ICP & cerebral perfusion
Vomiting
 
Midazolam 0.2 mg/kg IV rapid push. 60-90s 15-30 min   Not recommended for RSI owing to slow onset of induction even with recommended doses.
Thiopental         Potent vasodilator & myocardial depressant
Can exacerbate
BP

Paralyze:

  • Depolarizing Neuromuscular Paralytic Agent
    • Succinylcholine 1-2mg/kg IV (DOC)
      • Onset: 30 sec
      • Duration: 12 min
    • Contraindications:
      1. Hyperkalemia
      2. Crush injuries
      3. Significant burn > 48 hr old
      4. Spinal cord injury > 48 hr old
      5. Denervating & neuromuscular disease (Muscular dystrophy, ALS, etc)
      6. Open globe eye injuries
      7. Renal failure ONLY if pt. is Hyperkalemic
         
  • Nondepolarizing Neuromuscular Paralytic Agents
    • Rocuronium 1 mg/kg IV
      • Onset: 45 sec
      • Duration: 40 min
      • Defasciculating: 0.06mg/kg; maintenance: 0.6mg/kg
      • SE: Tachycardia. Longer duration of action makes it a second choice to succinylcholine. Use if succinylcholine contraindicated
    • Vecuronium 0.15mg/kg IV
      • Onset: 90 sec
      • Duration: 75 min
      • Defasciculating: 0.01mg/kg; maintenance: 0.1mg/kg
      • SE: Prolonged recovery time in obese or elderly, or if there is hepatorenal dysfunction
Pass tube (intubate) & Placement verification:
  • BURP (Backward-Upward-Rightward-Pressure)
Post intubation Management
  • Auscultate in axillae & over stomach; Capnography; Air aspiration from tube; CXR.
Indication:
Failure to maintain airway tone
  • Swelling of upper airway as in anaphylaxis or infection
  • Facial or neck trauma with oropharyngeal bleeding or hematoma

Decreased consciousness and loss of airway reflexes

  • Failure to protect airway against aspiration - Decreased consciousness that leads to regurgitation of vomit, secretions, or blood

Failure to ventilate

  • End result of failure to maintain and protect airway
  • Prolonged respiratory effort that results in fatigue or failure, as in status asthmaticus or severe COPD

Failure to oxygenate (ie, transport oxygen to pulmonary capillary blood)

  • End result of failure to maintain and protect airway or failure to ventilate
  • Diffuse pulmonary edema
  • Acute respiratory distress syndrome
  • Large pneumonia or air-space disease
  • Pulmonary embolism
  • Cyanide toxicity, carbon monoxide toxicity, methemoglobinemia

Anticipated clinical course or deterioration (eg, need for situation control, tests, procedures)

  • Uncooperative trauma patient with life-threatening injuries who needs procedures (eg, chest tube) or immediate CT scanning
  • Stab wound to neck with expanding hematoma
  • Septic shock with high minute-ventilation and poor peripheral perfusion
  • Intracranial hemorrhage with altered mental status and need for close blood pressure control
  • Cervical spine fracture with concern for edema and loss of airway patency
Contraindication:
Relative
  • Anticipated "difficult" airway, in which endotracheal intubation may be unsuccessful, resulting in reliance on successful bag-valve-mask (BVM) ventilation to keep an unconscious patient alive
    • In this scenario, techniques for awake intubation and difficult airway adjuncts can be used.
    • Multiple methods can be used to evaluate the airway and the risk of difficult intubation (e.g, LEMON rule, 3-3-2, Mallampati class, McCormack and Lehane grade). Please refer to the Difficult Airway Assessment section below for details.
       
  • The "crash" airway, in which the patient is in an arrest situation, unconscious and apneic
    • In this scenario, the patient is already unconscious and may be flaccid; further, no time is available for preoxygenation, pretreatment, or induction and paralysis.
    • BVM ventilation, intubation, or both should be performed immediately without medications.