Rapid Sequence Intubation Putting It All Together For the Assistant

Rapid Sequence Intubation Putting It All Together For the Assistant
New Hampshire Division of Fire Standards & Training and Emergency Medical Services

What is “RSI” ? Ref: Manual of Emergency Airway Management “Rapid Sequence Intubation (RSI) is the administration of a potent sedative followed immediately by a rapidly acting neuromuscular blocking agent that produces rapid unconsciousness and motor paralysis to facilitate endotracheal intubation.” This procedure is only to be used by paramedics that are trained and credentialed to perform RSI by NH Bureau of EMS. Source: NH EMS protocols

RSI Assistant Why RSI Assistants?
Required as part of 2009 NHEMS Patient Care Protocol 5.4 RSI RSI Assistant retraining required every two years 2009 NHEMS Rapid Sequence Intubation (RSI) Protocol 5.4 This procedure is only to be used by paramedics that are trained and credentialed to perform RSI by NH Bureau of EMS. Either 2 RSI paramedics or 1 RSI paramedic and 1 RSI assistant must be present. 2 capable RSI certified providers and or 1 RSI capable provider and 1 RSI assistant are required to perform this procedure.

Role of the RSI Assistant
Assist an RSI certified provider during RSI emergency airway procedures. Be familiar and practiced with all basic and advanced airway equipment/adjuncts maintained on EMS unit. Be competent in basic airway management. Be familiar and practiced with rescue airways maintained on EMS unit. Combitube, EasyTube, LMA, and King-LT-D Capable team member, directed by RSI Provider

RSI Indication As determined by RSI Provider
As per NH EMS protocol RSI 5.4 Immediate, severe airway compromise in the context of trauma, drug overdose, status epilepticus, etc., where respiratory arrest is imminent. Basically, RSI is considered for patients requiring advanced airway management who would not tolerate awake intubations. GCS >3

Potential RSI Candidates
Patients requiring oxygenation/ventilation management and or positive pressure ventilation: Such as, Traumatic brain injury with ALOC Severe thoracic trauma (flail chest, pulmonary contusions with hypoxemia) Clinical condition expected to deteriorate Unconscious or ALOC with potential for or actual airway compromise or vomiting And patient has…… A clenched jaw An active gag reflex GCS >3

Contraindications As determined by RSI Provider
As per NHEMS Protocol 5.4 Extensive recent burns or crush injuries greater than 24 hours old. History of Malignant Hyperthermia Too risky, based on a Risk/Benefit Analysis performed by RSI provider.

Complications There are many for the RSI provider to consider
Increased intracranial pressure Increased intraocular pressure Increased intragastric pressure Aspiration due to decreased gag reflex Malignant hyperthermia Dysrhythmias Hypoxemia Airway trauma Failure to intubate / failure to ventilate DEATH

Preparation is the KEY for an organized, smooth intubation
Remember the 7 P’s!! Proper prior planning prevents piss poor performance! Remember the 7 P’s!!

RSI Procedure: The Seven P’s
1. Preparation 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

IF Endotracheal Intubation fails, there must be a back-up plan...
King-LTD LMA BVM Combi-Tube Cricothyrotomy

1. Preparation A two-part process: RSI assistants Assess the risks
1. Preparation – Assess the risks 1. Preparation A two-part process: Assess the risks Prepare the equipment, RSI assistants Must be familiar with the RSI procedure and all necessary airway equipment

1. Preparation – Assess the risks
RSI Assistants should as directed prepare the following equipment: Basic adjuncts Suction Adult BVM with O2 Source ETT equipment as requested by RSI Provider Alternative airways accessible and ready Combitube, EasyTube, LMA, King, and Commercial Trach Device ETT placement confirmation devices Capnography

How does the RSI Provider know if the patient is going to be difficult to intubate…
In most pre-hospital cases the airway needs managing regardless of the level of difficulty, and the provider is expected to do that, regardless of difficulty ….so what is the benefit of knowing a fancy system? ? …and does it really matter?

Some Predictors of a Difficult Airway
1. Preparation – Assess the risks Some Predictors of a Difficult Airway C-spine immobilized trauma patient Protruding tongue Short, thick neck Prominent upper incisors (“buckteeth”) Receding mandible High, arched palate Beard or facial hair Dentures Limited jaw opening Limited cervical mobility Upper airway conditions Face, neck, or oral trauma Laryngeal trauma Airway edema or obstruction Morbidly obese Trauma: immobilized – cannot align axis Peds: anterior and cephalad airway, large tongue, large occiput, small mouth, stiff/floppy omega shaped epiglottis (more horizontal) Obesity or very small Short Muscular neck Large breasts Prominent Upper Incisors (Buck Teeth) Receding Jaw (Dentures) Burns Facial Trauma S/S of Anaphylaxis Stridor FBAO Blood Vomitus Epiglottitis Dentures Tumors Impaled Objects Spinal Precautions Lack of adequate access

Objectives RSI Providers use the following mnemonics to help predict a difficult airway: MOANS LEMONS DOA

Difficult to Bag (MOANS)
1. Preparation – Assess the risks Difficult to Bag (MOANS) Performed by RSI Provider Mask Seal Obesity or Obstruction Age > 55 No Teeth Stiff

Difficult Laryngoscopy & Intubation
1. Preparation – Assess the risks Performed by RSI Provider LEMONS Not these lemons Look Externally Evaluate 3-3-2 Mallampati Score Obstruction Neck Mobility Scene and Situation

LEMONS Pt should be sitting, head in neutral position, mouth wide open, and tongue extended out as far as possible. The number classification is based on the structures that are visible. A Class I view is a Grade I Intubation 99% of the time A Class IV view is a Grade III or IV intubation 99% of the time Class IV: <1% prevalence (hard palate only visible) Severe Difficulty Intubating Class III: <13% prevalance (soft palate, base of uvula visible) Moderate Difficulty Intubating Class II: 40% prevalence (soft palate, uvula, fauces visible) No Difficulty Intubating Class I: 46% prevalence (soft palate, uvula, fauces, pillars visible) No Difficulty Intubating

Obstructions Laryngoscopic View Grades
LEMONS Obstructions Laryngoscopic View Grades Grade 1: Full aperture visible Grade 2: Lower part of cords visible Grade 3: Only epiglottis visible Grade 4: Epiglottis not visible Grade 1: Full aperture visible Grade 2: Lower part of cords visible Grade 3: Only epiglottis visible Grade 4: Epiglottis not visible

Difficult Cricothyrotomy
1. Preparation – Assess the risks Difficult Cricothyrotomy Performed by RSI Provider DOA Disruption or Distortion Obstruction Access Problems If you can’t bag and can’t cric, they’re DOA

Scene and Situation Scene safety, every crew members responsibility
Environment Do you have a reasonable chance to get the tube? Space, positioning, access Egress Will you be able to ventilate during egress? A respiratory rate of 4 is better than a rate of 0!

RSI Assistant If endotracheal intubation proves difficult or fails for the RSI Provider. BE PERPARED Have Basic Adjuncts and BVM ready Consider two NPA’s and an OPA, + Cricoid pressure w/ gentle ventilation) Have Combitube, EasyTube, King LT-D or LMA setup and ready

Always have a back-up plan.
1. Preparation – Assess the risks Always have a back-up plan. Plans “A”, “B”, and “C” Know the answers before you begin Role of RSI Assistant

Plan “A”: (ALTERNATIVES)
1. Preparation – Assess the risks Plan “A”: (ALTERNATIVES) Different: Size of blade Type of blade Miller Macintosh Specialty Position (patient & provider) Hockey stick bend in ETT or Directional tip ETT Gum Elastic Bougie or Flex-guide Endotracheal Tube Introducer Remove the stylette as you pass through the cords “BURP” (aka “ELM”) 2-person technique “cowboy” or “skyhook” Type of blade Miller: anterior airway, big teeth, immobilized pt, floppy epiglottis Macintosh: better tongue control Specialty: Grand View; View Max, etc. It is important that the assistant be intimately familiar with all of these devices. The assistant should be able to identify and prepare the devices for the assistant, if asked. The assistant should be able to identify and prepare the devices for the advanced provider, if asked.

“BURP” – a.k.a. “External Laryngeal Manipulation”
1. Preparation – Assess the risks “BURP” – a.k.a. “External Laryngeal Manipulation” 90% of the time the best view will be obtained by pressing over the thyroid cartilage – because, anatomically, the vocal cords are connected here. “BURP”-backwards, upwards, right, pressure May help with difficult intubation Differs from the Sellick Maneuver

BURP Maneuver While the RSI assistant is applying the Sellick maneuver, the RSI Provider may ask for: Backward, Upward, Rightward Pressure: manipulation of the trachea Manipulate the trachea by pushing directly posterior and up to the patients right. The RSI Provider will be sweeping the oral anatomy to the patients left with a laryngoscope. This simple procedure will increase the RSI Provider chance of successfully placing the tube.

Plan “B”: (BVM and BLIND INTUBATION & BACKUP AIRWAY Techniques )
1. Preparation – Assess the risks Plan “B”: (BVM and BLIND INTUBATION & BACKUP AIRWAY Techniques ) Practice should include a failed intubation attempt and the assistant preparing the backup airway. The assistant can also practice with the backup airways per his/her level of licensure.

What do we do when faced with a “Can’t Intubate Can’t Ventilate” situation? Plan “C”: (CRIC) Commercial, Needle, or Surgical Last resort… The assistant should be able to identify and help prepare the cricothyrotomy devices for the advanced provider, if asked.

Always expect the unexpected!
1. Preparation – Assess the risks Always expect the unexpected! Mandibular Aplasia

1. Preparation - CONTINUED 2. Preoxygenate 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care We are still at PREPARATION

1. Preparation A two-part process: Assess the risks
Prepare the equipment

Prepare the Equipment Equipment is present, opened and ready for use
1. Preparation – Prepare the Equipment Prepare the Equipment Equipment is present, opened and ready for use Adequate Ambu-mask/oxygen sources/suction 2 laryngoscope handles Assortment of blades Assortment of ET tubes, stylette, syringe RSI Assistant Obviously the assistant should be able to perform any of these skills up to their level of licensure and be familiar with the set up of the advanced devices. Basics and Intermediates CANNOT prepare or administer RSI Medications, as it is outside the protocol.

Prepare the Equipment - continued
1. Preparation – Prepare the Equipment Prepare the Equipment - continued 1-2 secure IV lines All pharmaceutical agents needed for the procedure Back-up plan and rescue airway devices Oximetry and capnography monitoring Bulb-style tube checker If appropriate, explain procedure to patient

Monitor the Patient Cardiac monitor
1. Preparation – Prepare the Equipment Monitor the Patient Cardiac monitor Monitor for dysrhythmia's bradycardia, tachycardia, ectopy Blood Pressure monitoring (manual or NIBP) Monitor for hypo- or hypertension Pulse oximeter Monitor for hypoxia Waveform Capnography Monitor for hypo- or hypercarbia

1. Preparation - CONTINUED 2. Preoxygenate 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

2. Preoxygenation Preoxygenation Pre-oxygenate with 100% O2 via non-rebreather mask for at least 3-5 minutes Replaces the patient’s functional residual capacity (FRC) of the lung with oxygen “Nitrogen Washout” If done properly, this will permit as much as 3-4 minutes of apnea before hypoxia develops Rise of PaCO2 in apnea is not usually a significant concern unless the patient has a TBI or is severely compromised prior to intubation. PaCO2 rises about 3mmHg/min when the patient is apneic. FRC (functional residual capacity) in infants: 25 cc/kg (42 cc/kg in adults) Goal in preoxygenation is to replace the N2 in in the FRC with O2 O2 Consumption in infants: 5-8 cc/kg/min (gradually decreases with age to 2-3 cc/kg/min) **This predisposes peds to desaturation Most fully preoxygenated, healthy infants desaturate within seconds! In emergent cases, eight mask breaths with 100% oxygen may have to suffice. Assistant: You will most likely be responsible for the preoxygenation of your patient.

2. Preoxygenation Preoxygenation Resist the use of positive pressure ventilation (PPV). Use only if the patient is not ventilating adequately. PPV leads to gastric distention  regurgitation  aspiration If PPV is necessary, utilize cricoid pressure Place NG/OG if prolonged use of BVM Little known fact: Aspirating a few CC’s gastric contents increases the patients risk of death. Did we say cricoid pressure?

Cricoid Pressure Also known as “Sellick’s Maneuver”
4. Paralyze Cricoid Pressure Also known as “Sellick’s Maneuver” Should be automatic Begin just as Etomidate is administered Maintained until ETT placement is confirmed and tube is secure (cuff inflated) Used to occlude the esophagus and prevent passive regurgitation common with Succs If patient starts to actively vomit – RELEASE! and suction oropharynx. Otherwise, can lead to esophageal rupture Assistant: This an important role for you!

4. Paralyze Cricoid Pressure Frequently applied incorrectly. If too much pressure is applied, will obscure view of the cords Use thumb and forefinger to apply pressure directly backward/posterior over the cricoid cartilage.

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

Rapid Sequence Intubation Medications

Note about Medications
Medications are ONLY to be drawn, prepared, and administered by the Paramedic RSI Provider. The Basic or Intermediate Assistance cannot prepare RSI Medications, as they are not licensed or credentialed for their use.

3. Premedication Lidocaine Why: May prevent a rise in intracranial pressure in traumatic brain injured patients. When: At least minutes prior to intubation Onset: immediate Duration: minutes Mixed results regarding efficacy in decreasing ICP spike Standardized therapy at present – primarily for patients with suspected traumatic brain injury Also decreases the cough reflex and may decrease the incidence of post-laryngoscopy hypertension and tachycardia associated with intubation May also be give directly squirted into the posterior pharynx and trachea – may produce as much ICP spike, etc. as direct laryngoscopy Studies show ET suctioning and laryngeal manipulation cause an average ICP rise of 22 mmHg Assistant: Will not see any major change in patient.

Atropine Why: Given to prevent worsening bradycardia
3. Premedication Atropine Why: Given to prevent worsening bradycardia From Succs, vagal stimulation during direct visualization, and hypoxia When: Prior to intubation for bradycardic adults Atropine Onset: Immediate Duration: 4-6 hours Assistant: Will not see any major change in patient.

Etomidate Hypnotic induction agent
4. Paralyze Etomidate Hypnotic induction agent No analgesic properties Should always be given prior to paralytic Causes a slight elevation in arterial PaCO2, transient lowering of cerebral blood flow, moderate lowering of ICP lasting several minutes Etomidate: Dose Range: mg/kg. Some protocols call for a dose of 0.15 mg/kg in elderly or SBP<90. Ultrashort acting, nonbarbiturate hypnotic induction agent. Onset: seconds. Duration: <10 minutes. Half-life: 2.6 minutes. Does not cause hypotension or cardiovascular depression. Will lower ICP through reduced cerebral blood flow (20-30%) (also decreases O2 consumption). Etomidate decreases cerebral oxygen consumption, cerebral blood flow, and ICP but appears to have minimal effects on cerebral perfusion pressure. At therapeutic doses, Etomidate is characterized by hemodynamic stability without significant changes in mean arterial pressures, although a slightly increased heart rate may be observed. Has a tendency to induce vomiting – esp. if given rapidly. (*Also can causes adrenalcortical suppression - reduced cortisol and aldosterone - for up to 8 hours even after a single induction dose & unresponsive to ACTH stimulation -can be significant in pts with catecholamine depletion disease processes.) NOT effective at attenuating the hyperdynamic response to tracheal manipulation. Reports of hypertonus, coughing, laryngospasm, hiccoughs, and involuntary muscle movements(32% of pts) in 14-70% of pts. Premed with fentanyl 1mcg/kg helped. Etomidate + Fentanyl – study showed its efficacy when HTN and tachycardia are undesirable. Hepatic metabolism Assistant: Will see the patient become less responsive.

Will cause “fasciculations”
4. Paralyze Succinylcholine Why: Relaxes the patient’s muscles enabling the paramedic to intubate the patient. When: Immediately after Etomidate. Will cause “fasciculations” One Study: Trauma pts with RSI – Succs was associated with fewer difficult intubations that non-depolarizing NMBs May be given IM (not in state protocol) 3-4 mg/kg (max 150 mg total) onset: 2-5 minutes duration: 4-6 minutes Vial: 20mg/ml **“ONSET” for all of the paralytics = less time than it takes for there to be “optimum intubating conditions” Assistant: You will likely see the patient go through a brief period of fasciculation followed by complete flaccidity, as the patient becomes paralyzed.

4. Paralyze Fasciculations Muscular twitching involving the simultaneous contraction of contiguous groups of muscle fibers Merriam-Webster Dictionary

Paralyze A three step process:
Induction medications administered by RSI provider Cricoid Pressure, provided by RSI Assistant Constant vigilance for necessary intervention (i.e suctioning, hypoxia) Paralytic medications administered by RSI provider

5. Pass the Tube Pass the Tube Intubation is performed when there is full relaxation of the airway muscles About 90 seconds after Succinylcholine If intubation fails, maintain cricoid pressure and ventilate with BVM After patient is reoxygenated, reattempt or move to a different airway adjunct Assistant: You are still performing the cricoid pressure at this point.

Hold manual in-line axial stabilization
5. Pass the Tube Suspected Cervical Injury? Hold manual in-line axial stabilization Myth that pts with c-sp injuries cannot be safely intubated orally with RSI – FALSE!! BUT – you must have MIAS in place. Additional providers will be needed to hold in-line axial stabilization

Pass the Tube COMPLICATIONS:
If the paramedic misses or is unable to intubate after 30 seconds be prepared to…… Ventilate with BVM / high flow O2 with cricoid pressure maintained They may make ONE more attempt to intubate If still unsuccessful – continue BVM / Cricoid pressure Secure Airway with backup device (CombiTube, LMA or King-LT-D) Assistant: The advanced provider may ask you to perform the BURP maneuver to better visualize the cords.

5. Pass the Tube If ETT Unsuccessful If unable to intubate, unable to secure the airway with backup device, and unable to maintain an SpO2 of >90% with a BVM RSI Provider should contact Med Control The medications administered by the RSI Provider to facilitate intubation will wear off in several minutes.

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care We are still at PREPARATION

6. Proof of Placement Proof of Placement OBJECTIVE Direct visualization BEST CXR (in hospital) Pulse oximetry Capnography CO2 detectors Easy Cap - colormetric Self-inflating bulb SUBJECTIVE Absence of abdominal sounds while ambu- bagged Mist in the tube Bilateral breath sounds Rise/fall in chest USE at least 3 OBJECTIVE METHODS OF ETT CONFIRMATION, including capnography waveform when possible: direct visualization SIB CO2 detectors CXR Confirm placement using at least 3 methods, including capnography waveform. Assistant: Be familiar with the set-up and/or assembly of the various confirmation devices as you will likely be called upon to connect them.

SpO2 (Pulse Oximetry) Provides quick estimate of PaO2
6. Proof of Placement SpO2 (Pulse Oximetry) Provides quick estimate of PaO2 Often referred to as an additional vital sign Non-invasive

Waveform Capnometry Number of important applications
6. Proof of Placement Waveform Capnometry Number of important applications Monitor & Confirm ETT placement Useful to document adequacy of ventilation during mechanical ventilation Limitations: For patients with impaired pulmonary function or hemodynamic instability Assistant: Become familiar with the appropriate waveform for a properly ventilated patient.

Waveform Capnometry Prerequisite Requirement
6. Proof of Placement Waveform Capnometry Prerequisite Requirement Becoming a standard of care Easy to Use Good measure of Pulmonary Perfusion Relates well to PaCO2 Does have limitations

The Capnogram Represents the Respiratory Cycle Exhalation Inhalation
6. Proof of Placement The Capnogram Represents the Respiratory Cycle Exhalation A to D Inhalation D to E

After confirming placement:
6. Proof of Placement After confirming placement: RSI assistant should secure airway device with commercial device Immobilize the head with a cervical collar RSI provider must verify correct placement each time the patient is moved Continue to monitor Waveform capnography SpO2 Vital Signs Patients LOC Assistant: Be familiar with these steps and be able to perform.

7. Post Intubation Care Sedation Assessment Sign/symptoms Movement Increase in heart rate Increase in blood pressure Decrease in SpO2 Changes in muscle tone Facial muscle tension Assistant: Pay close attention to the patient’s level of consciousness. Should the patient at anytime show any of these signs/symptoms of discomfort inform the advanced provider immediately!

RSI Sequence Timeline Time -5 minutes Preoxygenation
Time -2 minutes Premedication Time -0 minutes Sellick Maneuver, Induction Agent, Paralytic Time +1 minutes Intubation T (5 minutes before RSI) Preoxygenation T-3 (3 minutes before RSI) Premedication T-0 (at time of RSI) Sellick maneuver, Induction agent, paralytic T+1 (1 minute after above medications given) Intubation

Medication Sequence Oxygen Lidocaine and/or Atropine if indicated
Etomidate Cricoid Pressure Succinylcholine INTUBATION Lorazepam prn Rocuronium or Vecuronium prn

Can't Intubate Can't Ventilate

Know Your Options!!! & Don’t hesitate to use them!

Rescue Airway Management
Have a back-up plan Algorithmic approach BVM Gum Elastic Bougie Laryngeal Mask Airway (LMA) Esophageal Tracheal Combitube King-LT-D Become familiar with the rescue airway carried on your EMS unit. Discuss drawbacks and benefits of each Assistant: Be familiar with the set-up and/or assembly of the various backup devices as you will likely be called upon to assist with them.

Assistant: You will most likely be performing this skill.
BVM Can you obtain a good mask seal? Adequate chest rise & fall? Adequate oxygenation & ventilation? Assistant: You will most likely be performing this skill.

Gum Elastic Bougie (GEB) or Flex-guide (FG) Endotracheal Tube Introducer
This is a device used by the paramedic to assist in endotracheal tube placement FG: 60cm long disposable, semi rigid, latex-free polyethylene instrument that is narrow enough to be passed through a 6mm ID ETT. Both ends are smooth and rounded to avoid tissue injury. The tip is angulated to approx. 45 degrees which facilitates passage of the FG anteriorly into the trachea when only the epiglottis is visualized. An ETT is then passed over the FG into the trachea. Following placement of the ETT, the FG is removed

LMA Good temporizing measure Multiple sizes
Aspiration likely if vomiting occurs Pre-Hospital use unproven/unpublished Risk of aspiration Controversy: The design of the mask makes aspiration likely if vomiting or regurgitation occur during ventilation through the mask.

Combitube Especially suited for… Patients with difficult anatomy
Reduced access spaces Reduced illumination (bright light) 95% of time will pass into the esophagus

King-LT-D

Failed Airway – What is it???
Unable to intubate (including blind rescue devices) and unable to ventilate with a BVM and maintain an Sp02 > 90 %.

Cricothyrotomy RSI Providers last resort for airway control
Low frequency/high risk skill Can be complex and confound decisions Refer to BEMS Cricothyroidotomy power point training module

Final Thoughts on the “Failed Airway”
In all cases of a failed airway, the operator must continually assess the adequacy of oxygenation and ventilation 7% of all trauma patients will require intubation

Golden Rule-Do No Harm “Always weigh the risks and benefits of intubation in the prehospital setting against transport to the ED. In many circumstances, rapid transport might be the best way of managing the airway.” Manual of Emergency Airway Management

Do No Harm “Master bag-and-mask ventilation. There are very few airway emergencies in the prehospital setting that will not be temporized or managed adequately with proper bag-and-mask ventilation until the patient can be transported to the hospital.” Manual of Emergency Airway Management

Documentation Required
Responsibility of the RSI Provider EMS Agency and Resource Hospital Medical Director are required to CQI/QA 100% of prehospital RSIs

Case Studies

Case 1 67 y/o female “code blue” – in asystole. RSI or not??? PLAN?
ETI needed, no RSI meds needed

Case 2 72 y/o female with Hx fever, productive cough and progressive dyspnea. Lethargic, perioral cyanosis. RR 34 and labored, HR 114, BP 117/76. Lung sounds equal with scattered rhonchi. RSI or not??? PLAN? Pt needs RSI – her condition is likely to deteriorate. Medicate with Etomidate and Succs.

Case 3 41 y/o female with c/o “asthma attacks” x20 minutes. Severe respiratory distress. RR 32, HR 127, BP 160/92. Bilateral I/E wheezes. Within 10 minutes, she becomes lethargic and her RR slows. RSI or not?? PLAN? Needs RSI. Etomidate and Succs.

Case 4 46 y/o male with a Hx of EtOH and drug abuse. Presents with “had a seizure” per bystanders. Pt is responsive to pain, but does not follow commands or answer questions. RR 18, HR 109, BP 120/80. Within minutes, he has 2 episodes of vomiting and “gurgling respirations”. PLAN? Needs RSI – cannot protect his airway, ALOC. May have a CHI. Consider pre-treating with Lido. Medicate with Etomidate and Succs. Lido for possible CHI/ICP.

Case 5 25 y/o male with GSW to abdomen. Pt is intoxicated, decreased LOC, minimal gag reflex. RR 8-10, HR 120, BP 100/80. PLAN? Needs RSI – condition likely to deteriorate, needs surgical intervention, unable to protect his airway. Medicate with Etomidate and Succs.

Case 6 87 y/o male MVC, high-speed, unrestrained. Patient gasping for air, able to talk, c/o right side CP. RR 32, HR 120, BP 186/92. Multiple deformities to face and chin. Ecchymosis and swelling to neck and anterior chest. Large flail segment to ant/lat chest. Decreased BS on the right. No stridor, but some gurgling in throat. PLAN? Needs ETI. Awake oral would be preferred – his airway is most likely distorted and his muscle tone may be the only thing keeping his airway open. He needs rapid evaluation and + pressure ventilation for his flail chest. He also needs a chest tube on the right. Know you might not succeed with RSI. Have rescue devices ready.

References Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc. Miller: Miller's Anesthesia, 6th ed., Copyright © 2005 Elsevier Roberts: Clinical Procedures in Emergency Medicine, 4th ed., Copyright © 2004 Elsevier

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