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RSI & Difficult Airway Review

RSI Considerations
? Rapid Sequence Induction (RSI)
should be considered in all patients
requiring emergency intubation
except those who are:
• In cardiac arrest
• Deeply comatose

? 1. Assess the risks
? 2. Get equipment
ready
? 3. Monitor the
patient
? 4. Pre-oxygenate
the patient
? 5. Medicate the
patient
TEMS RSI
10 steps

TEMS RSI
10 steps
? 6. Sedation and
Paralysis
? 7. Sellick’s
Maneuver
? 8. Intubate the
patient
? 9. Verify placement
? 10.Secure the
endotracheal tube

ASSESS THE RISKS
DIFFICULT AIRWAY:
Difficult to mask ventilate
Difficult to intubate

Complexity
The difficult airway represents a
complex interaction between
patient factors, the
prehospital/clinical setting, and
the skills of the EMS provider.

Difficult Airway Characteristics
? Beard
? No Teeth
? Large Tongue
? Small mouth opening
? Protruding upper teeth
? Recessed lower jaw
? Head size/shape
? Arthritis

Difficult Airway Characteristics
? Spinal Curvature
? Tumors
? Infections
? Trauma
? Obesity
? Previous Airway Surgery
? Congenital problems
? Pregnancy

Equipment to have ready
includes:
? An appropriate sized BVM with
reservoir
? A hooked up and operational suction
unit with tonsil tip device
? Oxygen hooked to BVM

Equipment to have ready
includes:
? Laryngoscope with
blade and working
light
? Stylet for ETT
? Stethoscope
? Medications
? Secondary Airway
Devices

Secondary Airway Devices
? Combitube
? LMA
? King Airway

Personnel Needed:
? Minimum of 4 people
• RSI Paramedic
• Second ALS provider
for airway
• EMS provider for
Sellick’s maneuver
• Provider for ancillary
tasks

Monitoring the Patient
? Prior to using
RSI, the patient
will have
• Heart monitoring
• Pulse Oximetry
• Complete set of
vital signs

Pre-Oxygenation
? When a patient is paralyzed, all
respiratory effort will cease for as
long as the paralytic remains
effective.
? Place all patients on 100% Oxygen
as soon as decision is made to
intubate (if not before).

Bag and Mask Ventilation
? Generally speaking, a BVM should
only be used to assist natural
ventilations.
? Over aggressive BVM ventilation can
lead to gastric distension and
vomiting.

Bag and Mask Ventilation
? If it is necessary to
use BVM ventilations
to pre-oxygenate the
patient, the Sellick’s
maneuver should be
used to prevent
gastric distension.
? Maintain this
throughout the
procedure
Sellick’s Maneuver

Patient Packaging
? All patients who are candidates for
rapid sequence induction should be
packaged for transport prior to the
induction

Medicating the Patient
• Atropine
? Blocks vagal stimulation associated with
prolonged intubation
? Given to
• All pediatric patients
• Adults who are bradycardic
• Lidocaine
? Lidocaine is to be given to patients with suspected
increases in intracranial pressure.
? Lidocaine is thought to blunt rises in intracranial
pressure seen during intubation attempts

Sedation and Paralysis
? In the TEMS region, the sedative of
choice for induction is Etomidate with
Succinylcholine as the paralytic
agent of choice.

Warning!
? Paralysis is a frightening event for
the patient and should always be
preceded by the administration of a
sedative agent, such as Etomidate.

Sedation and Paralysis
? Midazolam (Versed)
– alternative
sedative
? Vecuronium
(norcuron) –
alternative paralytic

Intubation of Patient
? Don’t forget the
Sellick’s Maneuver

Intubation of the Patient
? Intubation is
performed after
paralysis of the
body has taken
place
• 45-60 seconds
following
Succinycholine
administration
• jaw relaxes
? Performed by I/P
proficient in skill

Intubation of the Patient
? If intubation
attempt fails,
Sellick’s maneuver
(cricoid pressure)
should be
maintained during
bag and mask
ventilations until
an ETT is placed or
a secondary airway
device is used

Intubation of the Patient
? If the initial attempt at intubation
is unsuccessful, remove the blade
and ventilate the patient with bag
and mask ventilation for 60 to 90
seconds
? 3 attempts by 2 providers

Secondary Airway Devices
? Approved
secondary airway
devices in the
TEMS region are:
• Laryngeal Mask
Airway
• Combitube
• King Airway

Cricothyrotomy
? Emergency
Airway
? Consider if
• Combitube
insertion is
unsuccessful AND
• BLS maneuvers
are unsuccessful
• Special situations
(i.e. respiratory
burns)

Verify Placement
? Once intubated,
tube placement is
to be confirmed
with:
• Auscultation
• End Tidal CO2
? Reassess
• Vitals
• Pulse oximetry

Endotracheal Tube Placement
? Confirmation of tube placement is
more important than the intubation
itself!

Reassessment
? Patient monitoring
is to continue at 5
minute intervals
with tube
reconfirmation
after each patient
movement.

Secure the Tube
? A commercial tube holder is
recommended

Secure The Tube
? Sedation will be needed to ensure
that the tube remains secure
during transport
? All patients intubated using RSI,
are to be sedated for the transport
to the hospital

Transportation of the Sedated
and Paralyzed Patient
? Versed is used for post-
intubation sedation in
the TEMS region
? Vecuronium is used for
maintenance of paralysis
? Additional security is
provided by placing
paralyzed patient in full
spinal immobilization

Transportation of the Sedated
and Paralyzed Patient
? The risk of
extubation is
higher in small
children and
infants
? Be Careful!!!

Critical Criteria Review
? Ensure that all
equipment
necessary for RSI
is assembled and
ready for use.
? This includes
readiness of a
secondary or
alternative airway
device.

Critical Criteria Review
? The goal for the
paramedic
engaged in a
rapid sequence
induction event is
the successful
completion of the
event.
? Intubation is only
one aspect of the
event. The RSI
event is
successful if the
patient is properly
ventilated with a
combi-tube or
BLS airway.