By:

Margaret D. Estevez
Rapid Sequence
Intubation
Definitions

Rapid Sequence Intubation is an important technique by
sedating and paralyzing the patient allowing for easier
intubation.
Sellicks Maneuver - A method of preventing regurgitation of
an anesthetized patient during endotracheal intubation by
applying pressure to the cricoid cartilage.
ETT endotracheal tube
ER - Emergency Room
Difficult Airway a clinical situation in which a conventionally
trained clinical physician or anesthesiologist experiences
difficulty with mask ventilation, tracheal intubation or both
EDD esophageal detector device
BVM Bag Valve Mask
LMA - laryngeal mask airway


EDD BVM
Laryngeal Mask Airway
Objectives
To standardized Rapid Sequence Intubation in ER
To ensure optimal care for patients need airway
management
This policy applies to all Rapid Sequence Intubation in
the department of Emergency Room
Hospital Policies on RSI

RSI should be performed by physicians possessing training,
knowledge and experience in the techniques and
pharmacological agents used in RSI.
Neuromuscular blocking agents and appropriate induction
agents should be used in the ER.
Preparation of appropriate medication and appropriate
patient, bed and intubator positions should take place before
performing RSI.
Airway assessment for difficulty should be done before RSI.
Difficult airway cart and crash carts should be available in the
area where the RSI will be performed.

The Anesthesiologist on-call should be notified for all
anticipated difficult airway and should be consulted for all
failed intubation
Difficult airway algorithm should be followed for anticipated
difficult airway
Anticipation of complication and immediate response should
take place for all RSI
All difficulties encountered during laryngoscope view should be
documented on the ED sheet.
RSI audit form should be filled by the nurse in charge of the
patient and signed by the team leader in charge of the shift.
Quality review and patient monitoring should be addressed
and audited on a regular basis by ER Quality Management
using the Quality Audit Form

Indications
1. Failure to maintain airway tone
Swelling of upper airway as in anaphylaxis or infection,
burns
Head, facial or neck trauma with oropharyngeal bleeding
or hematoma
2. Decreased consciousness and loss of airway reflexes
Failure to protect airway against aspiration - Decreased
consciousness that leads to regurgitation of vomit,
secretions, or blood
3. Failure to ventilate
End result of failure to maintain and protect airway
Prolonged respiratory effort that results in fatigue or
failure, as in status asthmaticus or severe COPD, CHF




4. Failure to oxygenate (ie, transport oxygen to
pulmonary capillary blood)
End result of failure to maintain and protect airway
or failure to ventilate
Diffuse pulmonary edema
Acute respiratory distress syndrome
Large pneumonia or air-space disease
Pulmonary embolism
Cyanide toxicity, carbon monoxide toxicity,
methemoglobinemia

5. Anticipated clinical course or deterioration (eg, need
for situation control, tests, procedures)
Uncooperative trauma patient with life-
threatening injuries who needs procedures (eg,
chest tube) or immediate CT scanning
Stab wound to neck with expanding hematoma
Septic shock with high minute-ventilation and
poor peripheral perfusion
CVA, Intracranial hemorrhage with altered mental
status and need for close blood pressure control
Cervical spine fracture with concern for edema
and loss of airway patency

Contraindications
1. Absolute
Total upper airway obstruction, which requires a surgical
airway
Total loss of facial/oropharyngeal landmarks, which requires
a surgical airway
2. Relative
Anticipated "difficult" airway, in which endotracheal
intubation may be unsuccessful, resulting in reliance on
successful bag-valve-mask (BVM) ventilation to keep an
unconscious patient alive
The "crash" airway, in which the patient is in an arrest
situation, unconscious and apneic.

Equipment
Laryngoscope
Laryngoscope handle,
No. 3 Macintosh (curved) blade, and No. 3 Miller
(straight) blade.
Endotracheal (ET) tube
Stylet
Syringe, 10 mL (to inflate ET tube balloon)
Suction catheter (eg, Yankauer)
Carbon dioxide detector (eg, Easycap)
Oral and nasal airways
Ambu bag and mask attached to oxygen source
Assistant for cricoid pressure

Intubation Equipment
Laryngoscope handle, No. 3 Macintosh (curved)
blade, and No. 3 Miller (straight) blade.
Laryngoscope handles with an assortment of Miller blades
(large adult, small adult, child, infant and newborn)
Laryngoscope handle with an assortment of Macintosh
blades (large adult, small adult, child, infant and newborn)
A Carlens double-lumen endotracheal tube, used for thoracic
surgical operations such as VATS lobectomy
An endotracheal tube stylet, useful in facilitating
orotracheal intubation
A cuffed endotracheal tube, constructed of
polyvinyl chloride
Positioning

In the neutral position, the oral, pharyngeal, and
laryngeal axes are not aligned to permit adequate
visualization of the glottic opening.
Place the patient in the sniffing position for adequate
visualization; flex the neck and extend the head. This
position helps to align the axes and facilitates
visualization of the glottic opening.
Recent studies have shown that simple head extension
alone (without neck flexion) was as effective as the
sniffing position in facilitating endotracheal intubation.


Proper alignment of the axes for tracheal
intubation.
THE 7 Ps of RSI

Preparation
Pre oxygenation
Pretreatment
Paralysis
Placement
Placement and Proof
Postintubation Management
Preparation
Continuous ECG, SPO2 and BP monitoring
Functional laryngoscope, and BVM with high flow
oxygen
Endotracheal tubes, stylet and a 10cc syringe
Alternate airway LMA and crycothyrotomy equipment
available
All the medications should be drawn up and labeled
An assessment should be made for difficult intubation
The suction should be on and ready
Tube confirmation equipment should be available
All Intravenous access should be secured and finally,
The bed should be positioned at the level of the
intubator built



Difficult Airway/Intubation Assessment



L.E.M.O.N.
L: Look externally

E: Evaluate the 3-3-2 rule
The chance for success is increased if the patient is able
to insert 3 of his or her own fingers between the teeth,
can accommodate 3 finger breadths between the hyoid
bone and the mentum and is able to fit 2 finger breadths
between the hyoid bone and the thyroid cartilage.




Hyomental distance (3 finger breadths)

Thyrohyoid distance (2 finger breadths)
M: Mallampati classification

The Mallampati assessment is ideally performed
when the patient is seated with the mouth open and
the tongue protruding without phonating.

A crude assessment can be performed with the
patient in the supine position to gain an appreciation
of the size of the mouth opening and the likelihood
that the tongue and oropharynx may be factors in
successful intubation.

Mallampati classification
O: Obstruction

Three signs of upper airway obstruction are:
1. difficulty swallowing secretions (secondary to pain
or obstruction)
2. stridor (an ominous sign which occurs when < 10%
of normal caliber of airway circumference is clear)
3. a muffled (hot-potato) voice

N: Neck mobility

The inability to move the neck affects optimal
visualization of the glottis during direct laryngoscopy.
1. Cervical spine immobilization in trauma (with a C-
collar) can compromise normal mobility.
2. Due to medical conditions such as ankylosing
spondylitis or rheumatoid arthritis.

Preoxygenation

Administer 100% oxygen for 5 minutes for
unconscious patients or 8 vital capacity deep breaths
on 100% oxygen for conscious patients.

Use the least assistance necessary to obtain good
oxygen saturation and adequate preoxygenation.
High-flow oxygen via nonrebreather mask may be
appropriate for a patient with good respiratory
effort.
High-flow oxygen via well-fitting bag-valve-mask
(BVM) without additional positive pressure (ie,
squeezing the bag) may be needed for those with
more respiratory compromise.
High-flow oxygen via BVM with positive pressure
assistance (squeezing the bag) is used only when
necessary.


Pretreatment

Consider administration of drugs to mitigate the adverse
effects associated with intubation.
Pretreatment medications are typically administered 2-3
minutes prior to induction and paralysis.
LOAD (ie, Lidocaine, Opioid analgesic, Atropine,
Defasciculating agents).


Pretreatment Medications



Medication Dose Indication
Lidocaine 1.5 mg/kg IV To decrease bronchospasm
and decrease intracranial
pressure
Fentanyl 3g/kg over 1
min
CAD, ICH, raised ICP, Aortic
Dissection, High BP
Atropine 0.02 mg/kg (min
0.01 mg, max
0.5 mg)
To prevent bradycardia in
children 10 years old who
are receiving succinylcholine
for intubation
Defasciculating Agents


Decreases muscle fasiculations caused by the
depolarizing agents (succinylcholine)
Attenuates rise in intracranial pressure
Agents used are the non-depolarizing blocking agents
(vecuronium, pancuronium etc.) usually 1/10 of
standard dose

Paralysis with Induction

INDUCTION AGENTS
Administer a rapidly-acting induction agent to produce
loss of consciousness.

NEUROMUSCULAR BLOCKING AGENTS
Administer a neuromuscular blocking agent immediately
after the induction agent.
Muscle relaxant
These medications should be administered as an
intravenous push.

Induction Agents

SEDATIVES IV DOSE
(mg/kg)
ONSET
(min)
EFFECT ON
BP
EFFECT ON
ICP
Midazolam 0.2-0.4 1-2 Minimal Minimal
Ethomidate 0.2-0.4 <1 Minimal 1
Thiopental 2-5 <1 1 1
Ketamine 1-2 1 Minimal 1
Propofol 2-3 <1 1 1
Paralytic Agents

Agent Dose (m/g) Onset
(min)
Duration
(min)
Succynyl
choline
1.5 1 3-5
Pancuronium 0.1 2-5 40-60
Vecurunium 0.1 3 30-35
0.25 1 60-120
Atracarium 0.5 3 25-35
Mivacarium 0.15 2-3 15-20
Rocuronium 1.0 1-1.5 30-110
Protection
Hold the Sellicks maneuver from
pretreatment through proof of
proper placement.

Placement with proof

Place the ETT
Confirm tube placement with at least three of any of
the following methods:
Visualize the ET tube passing through the vocal
cords
Observe color change on a qualitative end-tidal
carbon dioxide device.
Use the 5-point auscultation method: Listen over
each lateral lung field, the left axilla, and the left
supraclavicular region for good breath sounds. No
air movement should occur over the stomach.
EDD/Bulb Aspiration
Oxygen saturations maintained >95% at 1 minute
and 5 minutes
Chest X-Ray

Post Intubation Management

After the preceding procedures have been performed,
the following should be observed:

1. First, secure the ET tube into place.
2. Discontinue attempt and ventilate with 100% oxygen
if:
Thirty seconds has passed and/or oxygen
saturation has fallen below 91%; and
If the patient becomes a bradycardic
3. If intubation is unsuccessful, continue cricoids
pressure and provide BVM ventilation until the
paralytic agent wears off and consider the use of
LMA and failed intubation algorithm
4. Administer appropriate analgesic and sedative
agents for patient comfort, to decrease O
2
demand,
and to decrease ICP.
5. Maintain continuous ETCo2 monitoring
6. Continue sedation and paralysis as indicated
7. Monitor the patients response, including vital signs,
arterial blood gas values, cardiac monitor and
arterial oxygen saturation.


Walls Difficult Airway Algorithm
Complications of RSI
Esophageal intubation
Right mainstem intubation
Pneumothorax
Dental trauma
Postintubation pneumonia
Vocal cord avulsion
Failure to intubate
Hypotension
Aspiration
Increase ICP
Quality Audit Form
Patient ID: Team Leader:
Age: Date/Time:
Diagnosis:
Indication of RSI:
Patient Estimated Weight: _____ kg

Drug Used Dose Time Given
1
2
3
4
Methods Use for confirmation: Yes No
1. Breath sounds over lungs, none gastric
2. End-tidal CO2 color change
3. Bulb aspirator quickly inflates
4. O2 saturation >95% at 30 sec, 1 min,
5mins
Chest X-ray requested post intubation:
Chest X-ray seen by: ___________ MD
Complications: (Anytime during or post
RSI)
Yes No Actions
taken
1. Desaturation (<90% O2 sat)
2. Bradycardia (<60 bpm)
3. Inability to place tube on first attempt
4. Esophageal Intubation
5. Post Intubation Hypotension
6. Tube dislodgement
References:

1. http://emedicine. medscape.com/article/80222-
overview#a03
2. http://en.wikipedia.org/wiki/Rapid_sequence_induction
3.http://web.nmsu.edu/~lleeper/pages/Voice/moreno/equip
ment_picture_gallery.htm
4. https://ezcompetency.com/modules/4.php

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Thank you!