Pharmacology-Assisted Intubation (RSI)

Study Notes

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.

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.

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.

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.

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.

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.

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.

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.