Rapid Sequence Rapid Sequence InductionInduction

Rapid Sequence Induction (RSI) is the method Rapid Sequence Induction (RSI) is the method used to secure the airway in a used to secure the airway in a hemodynamically stable, spontaneously hemodynamically stable, spontaneously breathing patient. It is useful in patients who breathing patient. It is useful in patients who have a full stomach and therefore are at risk have a full stomach and therefore are at risk for aspiration.for aspiration.

Key PrinciplesKey Principles Anticipating and retrieving the appropriate Anticipating and retrieving the appropriate

supplies and equipment.supplies and equipment. Understanding and anticipating the Understanding and anticipating the

sequence of eventssequence of events Knowledge of the frequently used Knowledge of the frequently used

medicationsmedications

Risk Factors for Risk Factors for AspirationAspiration

Last oral intake is unknownLast oral intake is unknown PregnancyPregnancy Agitated/Combative requiring diagnostic Agitated/Combative requiring diagnostic

procedure procedure Traumatic injury-esp head injuryTraumatic injury-esp head injury IntoxicationIntoxication GI problems- Ex. Bowel ObstructionGI problems- Ex. Bowel Obstruction Altered LOC with compromised airwayAltered LOC with compromised airway

Aspiration is a serious Aspiration is a serious complication that causes:complication that causes:

Increased length of stayIncreased length of stay Increased cost of treatmentIncreased cost of treatment Increased chance of morbidityIncreased chance of morbidity

Contraindications for RSIContraindications for RSI

Allergies to medicationsAllergies to medications Severe oral, mandibular or anterior neck Severe oral, mandibular or anterior neck

traumatrauma Airway obstructionAirway obstruction Significant hypotension, profound shock Significant hypotension, profound shock

statestate Age less than 3 monthsAge less than 3 months

The goal of RSI is to rapidly The goal of RSI is to rapidly secure and control the secure and control the airway. Its all about TIME.airway. Its all about TIME.

RSI ProcedureRSI Procedure

PreparePrepare Pre-oxygenate patientPre-oxygenate patient Administer induction agentAdminister induction agent Administer rapid acting muscle relaxantAdminister rapid acting muscle relaxant Insert ET tubeInsert ET tube Verify placement of ET tube and ensure Verify placement of ET tube and ensure

airway is securedairway is secured Post intubation managementPost intubation management

SuppliesSupplies

Establish IV AccessEstablish IV Access Cardiac MonitorCardiac Monitor OxygenOxygen Pulse OximetryPulse Oximetry Suction- Wall and YankauerSuction- Wall and Yankauer Crash CartCrash Cart Ventilator Prepared for AttachmentVentilator Prepared for Attachment MedicationsMedications

Intubation SuppliesIntubation Supplies

Bag value maskBag value mask Ambu bagAmbu bag Assorted ET tubes- (size 7 or 8)Assorted ET tubes- (size 7 or 8) CO2 detectorCO2 detector Laryngoscope blades-Mac and MillerLaryngoscope blades-Mac and Miller Laryngoscope handleLaryngoscope handle StyletStylet LMALMA BougieBougie Fiberoptic scope accessFiberoptic scope access Cric or trach tray on standbyCric or trach tray on standby

Patient PreparationPatient Preparation

Brief history and assessmentBrief history and assessment Use the mnemonic AMPLEUse the mnemonic AMPLE A= AllergiesA= Allergies M= MedicationsM= Medications P= Past Medical HistoryP= Past Medical History L= Last MealL= Last Meal E= Existing CircumstancesE= Existing Circumstances

Patient PreparationPatient Preparation

Pre-OxygenationPre-Oxygenation

100% Oxygen- Non-rebreather mask or bag value 100% Oxygen- Non-rebreather mask or bag value maskmask

Pretreatment with medications to counteract Pretreatment with medications to counteract the body’s response to intubation. Intubation the body’s response to intubation. Intubation causescauses Increased ICPIncreased ICP Increased intraocular pressureIncreased intraocular pressure Hypertension and tachycardiaHypertension and tachycardia

Paralysis with InductionParalysis with Induction

Induction/Sedation ALWAYS proceeds Induction/Sedation ALWAYS proceeds paralysis.paralysis.

Induction agents should be administered Induction agents should be administered by or under direct supervision of persons by or under direct supervision of persons trained in the administration of general trained in the administration of general anesthetics and in the management of anesthetics and in the management of complications encountered during complications encountered during general anesthesia (anesthesiologist, ED general anesthesia (anesthesiologist, ED physicians)physicians)

Cricoid PressureCricoid Pressure

Application of pressure Application of pressure to the cricoid cartilage to to the cricoid cartilage to occlude the esophagus.occlude the esophagus.

Prevents the aspiration Prevents the aspiration of gastric contents.of gastric contents.

Do not release the Do not release the pressure until instructed pressure until instructed to do so.to do so.

Post IntubationPost Intubation

Monitor Vital Signs FrequentlyMonitor Vital Signs Frequently Confirm Placement of ET TubeConfirm Placement of ET Tube

End tidal CO2 End tidal CO2 AuscultationAuscultation Chest X-rayChest X-ray

Secure ET TubeSecure ET Tube Obtain Orders for Sedation and Pain Obtain Orders for Sedation and Pain

ControlControl Obtain Vent OrdersObtain Vent Orders