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RSI, A Stepwise Approach
Transcript of RSI, A Stepwise Approach
BY: AMAR PATEL
PHARM.D. CANDIDATE 2014
OSU/OHSU COLLEGE OF PHARMACY
RSI, A STEPWISE APPROACH
Rapid Sequence Intubation
A technique where a potent
sedative or induction agent
is administered almost simultaneously with a paralyzing dose of a
neuromuscular blocking agent
to facilitate rapid tracheal intubation.
Protection against aspiration
Access to the airway for intubation
Permits pharmacologic control of adverse responses to illness, injury, and to intubation itself
reparation (0-10 min)
Establish IV access
reoxygenation (0-5 min)
100% oxygen 10-15 L/min x 5 minutes if spontaneously breathing
Provide reservoir of oxygen during intubation
Provides maximum of 70% FiO2
retreatment (0-3 min)
aralysis with induction
Administration of a
followed by a
(neuromuscular blocking agent [
]), usually a couple minutes after premedications.
Types of NMBA's:
Use Total Body Weight
Adults: 1.5 mg/kg
Adolescents: 1 mg/kg
Infants/small children: 2 mg/kg
Rapid onset, short duration of action
Use Ideal Body Weight
Used when succinylcholine is contraindicated or for lengthened NM paralysis post-intubation
Slightly longer onset and duration of action
Less desirable due to longer onset of action and longer duration.
Does not exacerbate hyperkalemia
Pancuronium, Atracurium &
Not used in the ER
since they can often cause
and possibly cause autonomic
roof (0-45 sec)
Confirm tube placement
Where, when, order?
How many breaths?
ost-Intubation Management (0-90 sec)
Physician order for ICU long-acting
of ventilated patients
ositioning (0-30 sec)
Can assist with
of the glottic opening for
Sellick maneuver (
Does not reduce the risk of aspiration
Thumb and index finger apply cricoid pressure
7 P's to Successful Intubation
aralysis with induction
rotection & Positioning
lacement & Proof
0.3 mg/kg (if > 10 years old)
Rapid onset, short duration, cerebroprotective, not associated with hypotension, hemodynamically neutral compared to other agents.
2-5 mg in adults/adolescents
0.1 mg/kg (6mg max) in children
Possibility for hypotension, and fewer adverse events, better amnesia, and greater potency compared to diazepam
analgesic properties, bronchodilator, may increase intracranial pressure. Used for asthmatics or anaphylactic shock.
Patients with aortic dissection, abdominal aortic aneurysm and acute MI.
Rapid onset, short duration, cerebroprotective, decreases blood pressure and heart rate, antiemetic, and can be used in malignant hypothermia patients
Dose: 2-3 mcg/kg
Describe indications, contraindications, advantages, disadvantages and complications of endotracheal intubation
Describe the indications and contraindications of the medications used for RSI.
Be able to prepare the necessary medications for RSI
Understand the necessary steps for RSI
10% of paralyzing dose
Rapid loss of consciousness
to facilitate ease of intubation
Rapid-Sequence Intubation. American College of Emergency Physicians Clinical and Practice Management Policy Statements. Apr 2012. Available at: http://www.acep.org/Clinical---Practice-Management/Rapid-Sequence-Intubation/. Accessed 03 Feb 2014.
Caro D, Walls RM, Grayzei J. Neuromuscular blocking agents (NMBA) for rapid sequence intubation in adults. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA;2014.
Lafferty KA, Mosenifar Z, Filbin MR, et al. Rapid Sequence Intubation. Medscape Reference. 27 Nov 2013. Available at: http://emedicine.medscape.com/article/80222-overview#a16. Accessed 03 Feb 2014.
Epocrates Rx Online [Internet database]. San Mateo (CA): Epocrates, Inc. 2014. Available at www.epocrates.com. Accessed 03 Feb 2014.
Brunton LB, Lazo JS, Parker KL, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. Pg. 220-226. New York: McGraw-Hill; 2006.
Mace SE. Challenges and Advances in Intubation: Rapid Sequence Intubation. Emerg Med Clin N Am. 26 (2008): 1043-68.
Society of Critical Care Medicine and American Society of Health-System Pharmacists. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Am J Health Syst Pharm. 2002; 59:179–95.
Rapid Sequence Intubation Drug Kit (RSI kit) and Code Box. St. Charles Redmond. 2014.
Reynolds SF, Heffner J. Airway management of the critically ill patient: rapid-sequence intubation. Chest. 2005 Apr; 127(4): 1397-412.
Bauman KA, Hyzy RC. In: UpToDate, Manaker S (ED), UpToDate, Waltham MA. (Accessed 20 Mar. 2014.)
American Association for Respiratory Care (AARC). Removal of the endotracheal tube 2007 revision & update. Respir Care 2007. Jan; 52(1): 81-93.
. Neligan P. Weaning and Discontinuation of Mechanical Venilation. Critical Care Medicine Tutorials. Accessed 20 Mar. 2014. Available at: http://www.ccmtutorials.com/rs/Weaning/index.htm.
/complications related to drugs administered
due to prolonged intubation
" or "
Patients with elevated ICP and impaired auto-regulation
Fentanyl and lidocaine
Major vessel dissection or rupture, or ischemic heart disease
Reactive airway disease
Pediatric patients (<10yo) and patients at risk of bradycardia
involves the process of removal of an endotracheal tube from a patient.
Trauma to airways
Indications for Extubation
Patients who do not need further medical care (
PEEP </= 10 cm H20 and FIO2 </= 0.40
to clear secretions
of NM blockers
(airway protection not needed)
Equipment and Monitoring
Emergency surgical airway materials
Withdrawal Side Effect
so the patient does not wake up in pain.
If a patient has been administered a
< 7 days
, it is
okay to abruptly discontinue
There may be a
between the reduction of the sedative/analgesic agent and
when the patient wakes
When the Patient
A look into Extubation
Factors Warranting Extubation
Acute airway obstruction
Mucus or mechanical deformation
Vocal cord injury
Patients who are capable of
maintaining adequate ventilation
do not require high levels of positive airway pressure.
Prior to Extubation
No difficulties with intubation
around deflated cuff with positive pressure breaths
Post-Extubation Management and Assessment
Invasive/non-invasive measurement of arterial blood gas values
Document extubation complications
Assess need for reintubation
Noninvasive positive pressure ventilation
BP, HR, O2 sat, RR
Turned off sedation
Medications Involved during Extubation
Sedative, Analgesic, and NMBA
Gradual taper of dose or abrupt discontinuation
Conflicting data around efficacy in
preventing post-extubation stridor
If extubation is delayed due to a reduced cuff leak, may give a
short dose of glucocorticoid prior to extubation
Methylprednisolone 20 mg
Q4H for four doses
Methylprednisolone 40 mg
4 hours prior to extubation