1. Rapid Sequence Induction CPT James Rice, PA-C Program Manager Tactical Combat Medical Care

2. References Emergency Medicine, A Comprehensive Study Guide, Tintinalli, 6 th ed., McGraw-Hill, 2004 Emergency War Surgery, Third United States Revision, Chapter 9, Borden Institue, Walter Reed Army Medical Center

3. 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

4. “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!

5. “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.

6. 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%)

7. 6 P's of RSI Preparation Preoxygenation Pretreatment Paralysis (with induction) Placement of the tube Post intubation management

8. Preparation Remember that RSI is a team effort –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!!

9. 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?

10. 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

11. 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

12. 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

13. 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

14. 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

15. Required Medication Narcotic Amnestic, Anxiolytic Sedative Paralytic(s)

16. 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?

17. 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

18. 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

19. 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 re- manufactured in an unconstituted form Not in your SKO

20. 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

21. 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

22. 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

23. 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!! –Gather your RSI kit –Preoxygenate –Reconstitute meds/draw up NS in a 15cc syringe –Ensure a patent IV site –Attach pulse oximeter

24. 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

25. RSI Sequence Pre-medication Phase –Morphine –Versed –Lidocaine –Atropine

26. RSI Sequence Pre-medication Phase –Defasciculation (optional) Vecuronium 0.01mg/kg

27. RSI Sequence Cricoid pressure (Sellick Maneuver) –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…

28. RSI Sequence Sedate –Etomidate Wait about a minute, you should be able to appreciate the sedative effect

29. RSI Sequence Paralytic –Succinylcholine You should note paralysis within 60 seconds –Vecuronium You should note paralysis in 2-3 minutes

30. 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

31. 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 mid- eighties…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

32. RSI Sequence Tube verification –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)

33. 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

34. 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

35. 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

36. 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.

37. 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

38. Questions??