Pharmacology-Assisted Intubation (RSI) Module 8-2 PDF

Pharmacology-Assisted Intuba7on Module 8-2  OVERVIEW induction Rapid sequence intuba/on (RSI) is an airway management technique that produces inducing immediate unresponsiveness (induc/on agent) and muscular relaxa/on (neuromuscular blocki...

Pharmacology-Assisted Intuba7on Module 8-2  OVERVIEW induction Rapid sequence intuba/on (RSI) is an airway management technique that produces inducing immediate unresponsiveness (induc/on agent) and muscular relaxa/on (neuromuscular blocking agent) and is the fastest and most effec/ve means of controlling the emergency airway The cessa/on of spontaneous ven/la/on involves considerable risk if the provider does not intubate or ven/late the pa/ent in a /mely manner RSI is par/cularly useful in the pa/ent with an intact gag reflex, a “full” stomach, and a life threatening injury or illness requiring immediate airway control  INDICATIONS FOR INTUBATION AND MECHANICAL VENTILATION A – airway protec/on and patency B – respiratory failure (hypercapnic or hypoxic), increase FRC, decrease WOB, secre/on management/ pulmonary toilet, to facilitate bronchoscopy C – minimise O2 consump/on & op/mize O2 delivery D – unresponsive to pain, terminate seizure, prevent secondary brain injury E — temperature control (e.g. serotonin syndrome) F — For humanitarian reasons (e.g. procedures) and for safety during transport (e.g. psychosis)  PROCESS OF RSI Remembered as the 9Ps: Plan Prepara/on (drugs, equipment, people, place) Protect the cervical spine Posi/oning (some do this aYer paralysis and induc/on) Preoxygena/on Pretreatment (op/onal; e.g. atropine, fentanyl and lignocaine) Paralysis and Induc/on Placement with proof Post-intuba/on management  ROLES DURING RSI The airway team should be a minimum of 3 people: Airway proceduralist Airway assistant (e.g. MILS) Drug administrator The team leader may perform one of the above roles if necessary, but should ideally be a separate stand alone role.  PREPARATION FOR RSI Prepara7on requires control over: Self Pa/ent Others Environment: maintain a ‘sterile environment’ when communica/ng the airway plan to the team, ideally through one of these two mnemonics will help: SOAPME O2 MARBLES  SOAPME Suc/on — at least one working suc/on, place it between maaress and bed Oxygen — NRBM and BVM aaached to 15 LPM of O2, preferably with nasal prongs for apneic oxygena/on Airways — 7.5 ET tube with stylet fits most adults, 7.0 for smaller females, 8.0 for larger males, test balloon by filling with 10 cc of air with a syringe — Stylet – placed inside ET tube for rigidity, bend it 30 degrees star/ng at proximal end of cuff (i.e. straight to cuff, then 30 degree bend)  SOAPME — Blade – Mac 3 or 4 for adults – curved blade — Miller 3 or 4 for adults – straight blade — Handle – aaach blade and make sure light source works — Backups – ALWAYS have a surgical cric kit available! — have video laryngoscope, LMA and bougie at bedside Pre-oxygenate – 15 LPM NRM Monitoring equipment/Medica/ons — Cardiac monitor, pulse ox, BP cuff opposite arm with IV — Medica/ons drawn up and ready to be given End Tidal CO2  O2 MARBLES O2 MARBLES is an alterna/ve for the equipment and planning: Oxygen masks (NP, NRM, BVM); monitoring airway adjuncts (e.g. OPA, NPA, LMA); Ask for help and difficult airway trolley RSI drugs; Resus drugs BVM; Bougie Laryngoscopes; LMA ETTs; ETCO2 Suc/on; State Plan  O2 MARBLES Induc7on agents Ketamine 1.5-2 mg/kg Etomidate 0.3-0.4 mg/kg Fentanyl 2-10 mcg/kg 0 Midazolam 0.1-0.3 mg/kg Propofol 1-2.5 mg/kg Thiopental 3-5 mg/kg  d O2 MARBLES Neumuscular blockers (paraly7c agents): Suxamethonium 1-2 mg/kg Rocuronium 0.6-1.2 mg/kg Vecuronium 0.15-0.25 mg/kg Neuromuscular-blocking drugs, or Neuromuscular blocking agents (NMBAs), block transmission at the neuromuscular junc/on, causing paralysis (relaxa/on) of the affected skeletal muscles. This is accomplished via their ac/on on the post-synap/c acetylcholine (Nm) receptors.  Complica7ons Unrecognised esophageal intuba/on. Malposi/on. Aspira/on. Hypoxia. Laryngospasm. Oropharyngeal trauma. Vagal s/mula/on. The End