Airway Skills 4:
Rapid Sequence Intubation
The CALS pocket card for rapid sequence intubation (RSI) reads as follows:
| 1. Prepare: | Equipment, meds, team, patient (basic airway management, positioning) |
| 2. Preoxygenate: | 100% O2, 3 to 5 minutes |
| 3. Premedicate: | PEDS:
Atropine 0.02 mg/kg IV children
< 8 years
(min 0.1 mg) Adult: Lidocaine 1.5 mg/kg IV (head injury, asthma) |
| 4. Push the sedative: | Use
one: Etomidate 0.3 mg/kg IV: Use with caution in septic shock. Consider alternative sedation or supplemental corticosteroids OR Midazolam 0.1 mg/kg IV (adults) PEDS: 0.3 mg/kg IV: Suggested maximum single dose 10 mg; reduce dose or consider alternative in hypotension or elderly Ketamine 1 to 2 mg/kg IV (bronchodilator) Raises intracranial pressure; avoid in head injury. |
| 5. Paralyze: | Use
one: Succinylcholine 2 mg/kg IV Avoid in hyperkalemia, neuromuscular disease, or ocular trauma OR Vecuronium 0.1 mg/kg IV OR Rocuronium 1 mg/kg IV. Wait for relaxation (45-60 sec). Do not bag unless hypoxic. |
| 6. Position airway: | Head/neck position; laryngeal manipulation, BURP, cricoid pressure as neededa |
| 7. Pass the tube: | Maintain in-line cervical immobilization in head/neck trauma |
| 8.
Patent airway assessment: |
Use esophageal intubation detector, check breath sounds, CO2 detector |
| 9.
Post-intubation plan: |
Drugs and dosages depend on medications
used during intubation Sedation: Midazolam 0.05 mg/kg to 0.3 mg/kg IV. Suggested maximum single dose 10 mg; reduce dose or consider alternative in hypotension or elderly Paralysis: Vecuronium 0.1 mg/kg IV (if not used for intubation) Analgesia: Fentanyl 1 to 2 MICROgrams/kg IV Morphine 0.05 to 0.15 mg/kg IV Consider need for seizure prevention. |
Repeat as needed to maintain sedation, paralysis, and analgesia.
The Steps of RSI ( Vol III—AIR 1 Rapid Sequence Intubation)
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Preparation. Team members must be prepared to measure and administer the appropriate drugs. The following is important:
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Position the patient for optimal basic airway management.
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Have available a small drug kit containing all of the RSI drugs along with dosage charts and checklists.
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Have available an airway cart with all critical pieces of equipment.
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Know the skills of cricoid pressure and BVM ventilation.
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If possible, obtain a SAMPLE history; perform mini-neuro and rectal exams.
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Know and have available backup tools.
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Secure IV access.
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Limit number of drugs used. Be familiar with indications and contraindications.
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Practice good communication among team members.
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Preoxygenate. This may require 5 minutes breathing oxygen through a tight-fitting mask. If patient can be at or near 100% saturation, they can tolerate up to 4 minutes of apnea with minimal decrease in saturation.
If time is short, simply administer 4 good vital capacity volumes of oxygen by BVM to avoid a drop in saturation.
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Premedicate. Give all premedication 2 minutes before intubation if possible.
PEDS: Administer atropine in children aged < 8 years, although this age is an arbitrary cutoff. The dose is 0.02 mg/kg IV with a minimum dose of 0.1 mg/kg.
Lidocaineb (1.5 mg/kg) IV is used in patients in whom an intracranial pressure (ICP) rise would be detrimental. The proof of this method is not well documented, but lidocaine has few side effects and may well be effective. It may have a bronchodilator effect, so it is often recommended in asthma cases also.
Push the sedative.
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Etomidate (Amidate) is a hypnotic anesthetic with many advantages over other sedatives and few negative properties.c The dose of etomidate is 0.3 mg/kg IV.
The benzodiazepine midazolam is another choice for induction. The dose is 0.1 mg/kg IV (adults) and PEDS: 0.3 mg/kg IV.
Another choice is ketamine (Ketalar) 4 mg/kg IM or 1 to 2 mg/kg IV. Ketamine does not reduce blood pressure but raises ICP. Its bronchodilator effect is modest at best, but it is frequently recommended for RSI in asthma patients.
Paralyze. The dose of succinylcholine is 1.5 to 2 mg/kg IV in adults and (PEDS) 2.0 mg/kg IV in children.d If hyperkalemia is a problem, a second choice would be vecuronium 0.1 mg/kg IV or rocuronium 1 mg/kg IV.
Wait for relaxation (45-60 seconds). Do not bag unless patient is hypoxic.
Position the airway.
Position the patient’s head and neck for optimal visualization of the airway. When c-spine injury is not a concern, the head should be extended and the occiput slightly elevated (adults). PEDS: In young children, the shoulders should be slightly elevated with a rolled towel. In cases of potential c-spine injury, the neck must be kept in neutral position and manual in-line stabilization provided.
Position the larynx for optimal visualization using backward, upward, rightward pressure (BURP) applied externally to the thyroid and cricoid cartilage. This may be done by the intubator or by an assistant.
Direct pressure over the cricoid cartilage (Sellick’s maneuver) is an optional technique that may be useful in preventing gastric distention and regurgitation during RSI.
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Pass the tube. The techniques of oral intubation are described in Vol II—Air Skills Portals. Teamwork is essential, especially in trauma patients who are usually in cervical collars and neck blocks. In-line immobilization is needed to protect the cervical spine.
If the first attempt at intubation fails, the patient can be briefly BVM ventilated to improve oxygenation; then another attempt may be made. Always have a back-up technique in mind.
Patent airway assessment. After the trachea is intubated, check to be sure that the tube is actually in the trachea and that it is in good position above the carina. Techniques useful to assess proper endotracheal tube placement include (in order of application):
Observation of chest rise with ventilation and auscultation of the epigastrium and chest
Use of an esophageal intubation detector (EID, Wee Aspirator)
Detection of end-tidal CO2
Pulse oximetry
Chest x-ray
Post-intubation plan. Take this opportunity to catch your breath and consider the next steps. The following concerns may need to be addressed: Continued sedation, paralysis, and analgesia. Drugs and dosages depend on medications used during intubation.
Sedation: Virtually all patients undergoing RSI require continued sedation after intubation. Midazolam 0.05 mg/kg to 0.3 mg/kg IV is a good choice (if not already used as the initial sedative for RSI). Suggested maximum single dose is 10 mg; reduce the dose or consider an alternative in hypotensive patients or the elderly.
Paralysis: Post-intubation paralysis is optional, but is often indicated. Indications include need for control of patient respiratory effort, immobilization for procedures, and need for transport. If succinylcholine (duration of action approximately 5 minutes) was used for paralysis during the intubation, it will be necessary to use a longer-acting neuromuscular blocking agent. Vecuronium 0.1 mg/kg is a reasonable choice.
Analgesia: Sedation and paralysis do not provide pain control. In painful conditions, consider Fentanyl 1 to 2 MICROgrams/kg IV or Morphine 0.05 to 0.15 mg/kg IV.
Repeat as needed to maintain sedation, paralysis, and analgesia.
References
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Donegan MF, Bedford RF. Intravenously administered lidocaine prevents intracranial hypertension during endotracheal suctioning. Anesthesiology. 1980:52:516–518.
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Weiss LD, Generalovich T, Heller MB, et al. Methemoglobin levels following intravenous lidocaine administration. Ann Emerg Med. 1987;16:323-325.
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Zed PJ, Mabasa VH, Slavik RS, Abu-Laban RB. Etomidate for rapid sequence intubation in the emergency department: is adrenal suppression a concern? CJEM. 2006;8:347-350.
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Jackson WL Jr. Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock? A critical appraisal. Chest. 2005;127:1031-1038. 17. Luten RC, Kissoon N. Approach to the pediatric airway. In: Manual of emergency airway management. 2nd ed. Walls RM, Murphy MF, Luten RC, et al (eds). Philadelphia Pa: Lippincott Williams and Wilkins, 2004. 18. McAllister JD, Gnauck KA. Rapid sequence intubation of the pediatric patient. Fundamentals of practice. Pediatr Clin North Am 1999;46:1249-1284.