1. Intro to:

2. Objectives  Define RSI  Identify the Indicators for using RSI  Identify the relative contraindications and disadvantages of RSI  Discuss the different roles in the RSI process  Review the crucial 7 P’s of RSI  Review the medications used during RSI  Review a difficult airway and identify alternative tools and techniques

3. What is RSI?

4. Why RSI?  Respiratory failure  Inability to protect own airway  Impending or potential airway compromise  GCS less than 8  Intractable seizures

5. Relative contraindications to RSI  Airway obstruction  Distorted anatomy  Major facial or laryngeal trauma  Angioedema

6. Disadvantages of RSI  Hypoxia if unable to complete intubation  RSI blocks the patient’s involuntary reflexes and muscle tone in the oropharynx and larynx  Adverse medication reactions  Masks underlying symptoms  Requires considerable amount of training and recurrent training

7.  The benefit of obtaining airway control must always be weighed against the risk of complications in these patients.  You are taking a breathing patient and making them APNEIC

8. RSI Equipment  Airway equipment (ET, syringe, stylette, etc)  Oxygen  Suction equipment  Ecg monitor  IV equipment  SaO2 monitor  Capnography  RSI meds

9. It’s a team effort!  Skilled intubator  Timekeeper/scribe  Vital sign monitor  Medication administrator  Assistant

10. Before you get started…. In the ideal world  Get medical history  Obtain baseline neuro exam  Check all your equipment  Confirm pt. weight

11. 7 Essential P’s of RSI  Preparation  Pre-oxygenate  Pre-medicate  Paralysis and Induction  Protection  Placement of the tube  Post Intubation management

12. Preparation  Prepare all equipment including ETT, suction, pulse oximeter, IV and monitor  Position patient in sniff position if C-spine immobilization is not indicated.

13. Pre-Oxygenate  Pre-oxygenate with 100% oxygen via NRB for at least 3 min. or 8 vital capacity breaths with 100% oxygen.  If ventilatory assistance is necessary with BVM, be gentle and apply cricoid pressure.

14. Do you predict a difficult airway?  Short neck or no neck  Small mandible  Obesity  Facial/maxillary trauma  Edema or infection  Degenerative spinal disease

15. What does a difficult airway mean to you?  Be prepared!  Have plan B, C, and D if intubation fails.

16. Tools for a difficult airway  Have one ETT tube size smaller & bigger available  ETTI (Bougie, Eshman, etc)  Back up devices (Combitube, King airway)  Surgical airway kit

17. Are you ready?

18. What drugs do we use?  Oxygen Ventilate while preparing for RSI  Lidocaine?  Atropine?  Versed  Etomidate  Succinylcholine  Vecuronium

19. Procedure  Pre-oxygenate – (NOT hyperventilate) for 2 – 3 min.  Assemble equipment  Proximal IV preferred  Connect pt. To monitor  Lidocaine (TBI)  Atropine (children < 10)  Versed  Etomidate  Succinylcholine  Sellick maneuver

20. Procedure, cont.  Stop ventilations  Observe for fasiculations  Intubate If unable to ventilate in 20 sec., stop and ventilate for 30 – 60 sec. May give second dose of Sux (1 – 1.5 time initial dose If bradycardia occurs, give Atropine and hyperventilate  Confirm intubation  Attach Easy Cap or capnography device  Administer Vecuronium  MONITOR PATIENT

21. Protect the Patient  Maintain cervical stabilization prn  Maintain cricoid pressure until tube placement is confirmed and secured.  Constant vigilance of monitoring oxygenation

22. Whose tube is it?  The most experienced medic!  If unable to intubate within 20 seconds or SaO2 drops below 92%, STOP and ventilate with BVM  Confirm placement  Release cricoid pressure

23. How did you confirm the tube?  Gold standard (visualized tube passing through the cords  Capnography  Mist in the tube  Bilateral breath sounds Recheck tube placement after every patient move, if airway resistance occurs or increases, hear rate decreases, or O2 desaturation occurs

24. Post medication  Continue paralysis with Vecuronium  Continue sedation with Versed  Consider pain control

25. What if you can’t get the tube in??  Provide 100% oxygen with BVM  Consider back up device  Consider surgical airway

26. All neuromuscular Blocking Agents:  Work by blocking the natural transmission of nerve impulses to skeletal muscles.  No direct effect on Heart, Digestive system, Brain, Pupillary response, Smooth Muscle or other organ systems  No effect on mentation or pain perception!  No direct effect on seizure activity.

27. Remember….  If performed correctly, RSI will take between 7 – 10 minutes.  You are taking a breathing patient and making them apneic.  Always be prepared and know your RSI protocol.