Pharmacology-Assisted Intubation (RSI)

Pharmacology-Assisted Intubation (RSI)

• RSI is a rapid airway management technique using induction agents and muscle relaxants for immediate unresponsiveness and relaxation.
• It's the fastest and most effective method for controlling the emergency airway.
• Cessation of spontaneous ventilation poses significant risk if not addressed promptly.
• RSI is crucial for patients with an intact gag reflex, full stomach, or life-threatening injuries requiring immediate airway control.

Indications for Intubation and Mechanical Ventilation

• Airway protection and patency (A): Maintaining a clear airway.
• Respiratory failure (B): Hypercapnic or hypoxic conditions; increasing functional residual capacity (FRC), decreasing work of breathing (WOB), and facilitating secretion management/pulmonary toilet for bronchoscopy.
• Optimizing oxygen delivery (C): Minimizing oxygen consumption, terminating seizures, and preventing secondary brain injuries.
• Unresponsiveness to pain (D): Terminating seizures and preventing secondary brain injuries.
• Temperature control (E): Managing conditions like serotonin syndrome.
• Humanitarian reasons/safety during transport (F): Procedures and scenarios like psychosis.

Process of RSI (9Ps)

• Plan: Develop a thorough plan.
• Preparation: Gather all necessary drugs, equipment, personnel, and location.
• Protect the cervical spine: Prevent spinal injury.
• Positioning: Position patient (some perform this after paralysis and induction).
• Preoxygenation: Maximizing oxygen saturation before induction.
• Pretreatment (optional): Administer medications like atropine, fentanyl, and lignocaine.
• Paralysis and Induction: Administer paralytic agents and induction agents to achieve unconsciousness.
• Placement with proof: Secure endotracheal tube placement and document.
• Post-intubation management: Plan for post-intubation care.

Timelines for RSI

• A detailed timeline for the procedure stages (preparation, preoxygenation, treatment, paralysis, induction, placement verification, and post-intubation) is presented using a visual, flow chart-like format.

Roles During RSI

• The airway team should comprise a minimum of three members:

  • Airway proceduralist
  • Airway assistant (e.g., MILS)
  • Drug administrator

• A team leader may also perform the role of one of the above, but ideally they should have a separate, distinct role.

Preparation for RSI (SOAPME)

• Self-assessment: Ensure one's own readiness for the procedure.
• Patient assessment: Evaluate the patient's condition.
• Others (team) assessment: Confirm that other team members are ready and have necessary equipment.
• Environment: Maintain a safe and sterile environment.
• Communicating airway plan: Use standardized mnemonics such as SOAPME or O2 MARBLES.

Equipment and Supplies (SOAPME)

• Suction: Verify a functional suction device is available.
• Oxygen: Utilize nasal prongs, non-rebreather mask (NRBM), and bag-valve-mask (BVM) at 15LPM.
• Airway: Endotracheal tubes (ETTs) with appropriate stylet size and testing.
• Laryngoscopes: Appropriately sized (Mac or Miller).
• Backups: Have extra equipment on hand (cricoid, video laryngoscope, LMA, etc.).
• Pre-oxygenation: 15 LPM NRBM.
• Monitoring: Cardiac monitor, pulse oximeter, blood pressure cuff, and IV medications.
• End tidal CO2: Monitor end tidal carbon dioxide level.

Equipment (O2 MARBLES)

• Oxygen: Masks (e.g. nasal prongs, non-rebreather mask, bag-valve-mask), monitoring.
• Airway management: Adjuncts (e.g. oral pharyngeal airway (OPA), nasopharyngeal airway (NPA), laryngeal mask airway (LMA)), and use of difficult airway trolley.
• Drugs: RSI drugs; resus drugs.
• BVM and bougie: Essential airway devices.
• Laryngoscopes, ETTs and ETTCO2: Essential equipment for intubation.
• Suction: Verify function and placement
• Procedure plan: Outline the plan.

Induction Agents (O2 MARBLES)

• Ketamine: 1.5–2 mg/kg.
• Etomidate: 0.3–0.4 mg/kg.
• Fentanyl: 2–10 mcg/kg.
• Midazolam: 0.1–0.3 mg/kg.
• Propofol: 1–2.5 mg/kg.
• Thiopental: 3–5 mg/kg.

Neuromuscular Blockers

• Suxamethonium: 1–2 mg/kg.
• Rocuronium: 0.6–1.2 mg/kg.
• Vecuronium: 0.15–0.25 mg/kg.

Complications

• Unrecognised oesophageal intubation
• Malposition
• Aspiration
• Hypoxia
• Laryngospasm
• Oropharyngeal trauma
• Vagal stimulation