Rapid sequence intubation

RSI is the process of simultaneous administration of an induction and a neuromuscular blocking agent to Facilitate Tracheal Intubation And Is Preferred For Emergency intubation

1. Dr. Ashutosh kumar singh
RSI
RapidSequenceIntubation

2. Definition
RSIistheprocessofsimultaneousadministrationofan
inductionandaneuromuscularblockingagentto
FacilitateTrachealIntubationAndIsPreferredFor
Emergencyintubation
Aim:Tointubatethetracheaasquickly&safelyas
possible

3. Indications for RSI
•airway protection and patency
•respiratory failure (hypercapnic or hypoxic),decrease
WOB.
•minimise oxygen consumption and optimize oxygen
delivery (e.g. sepsis)
•unresponsive patient, seizure, prevent secondary
brain injury.
•For humanitarian reasons (e.g. procedures) and for
safety duringtransport

4. Contraindications of RSI
Airway Obstruction
Allergy to Anaesthetic medications
Severe oral or mandible trauma

6. 6 P’s of RSI
•Preparation
•Pre-Oxygenation with 100% oxygen
•Pre-treatment & Induction
•Paralysis +/-Cricoid pressure
•Placement of the tube
•Post intubation management

7. Preparation
Suction
—at least one working suction
Oxygen
—NRBM and BVM attached to 15 LPM of O2.
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

8. —Stylet
—laryngoscope should be ready
—Backups –ALWAYS have a surgical cric. kit
available!
—have video laryngoscope if available & a LMA at
bedside
Pre-oxygenate –15 LPM NRBM
Positioning
Monitoring equipment/Medications
—Cardiac monitor, pulse ox., BP cuff opposite arm with
IV ascess
—Medications for pre-treatment
End Tidal CO2

9. Pre-Oxygenation
Pre-Oxygenation
• Establish O2 reservoir
• Maximize time for intubation
• Prevent need for bag-mask ventilation
Methods:
• 3-5 minutes of 100% O2 via bag mask
• 5 Tidal capacity (5 Breaths)

10. Pre-Treatment
Pre-Treatment
• Mitigate adverse physiologic reactions to intubation
–Sympathetic “pressor response”
• Manipulation of airway, ↑ HR/BP,
–Bronchospasm
–Increased ICP
–Muscle Fasciculation
–“LOAD”

12. Induction
Given as rapid IV push immediately before paralysing
agent
• Facilitate LOC in one-arm-brain circulation time
minimize the time from LOC to intubation
• Should provide a rapid onset & a rapid recovery from
anaesthesia with minimal CVS & Systemic side effect.

14. Paralytics
Paralysis/NMB Agent
• Rapid onset of action to minimize risk of aspiration &
hypoxia
• Rapid recovery to facilitate the return of ventilation if
intubation fails
• Minimal hemodynamic & systemic effect
Wait for relaxation
-Do not bag unless hypoxic
-Insufflate air into the stomach & increase risk of
vomiting/aspiration

16. Technique
Cricoid Pressure:
Techniques
•Theoesophagusisoccludedbyextensionoftheneck
&applicationofpressureoverthecricoidcartilage
againstthebodyof5cervicalvertebratoobliterate
oesophageal
lumen
•Appliedanassistantwiththumb&fingerateitherside
ofcricoidcartilage
–Maintainuntilafterintubation&cuffinflation.

18. Placement
Tube position is confirmed by:
• Direct visualization of ET tube between the vocal
cord
• Auscultation: equal air entry
• Capnometer: EtCO2

19. What if Intubation Failed???
What if the intubation attempt is not successful?
1st step = bagmask ventilation for support
Rescue Maneuvers
–The first rescue from failed intubation is bagging
–The first rescue from failed bagging is better bagging

20. Post Intubation Mx
•ECG
•SPO2
•NIBP/Art-line
•Capnograph
•Nasogastric tube
•CXR
•ABG Post intubation
•Maintainace of sedation (+/-paralysis)
–Midazolam 0.2mg/kg
–Propofol 25-50μg/kg/min
Establish ventilator parameters