1/7/09 (UPDATED 1/11/08

RSI (Rapid sequence intubation)

Indications:

• Trauma with GCS of <9, with gag reflex or significant facial trauma
• Closed head injury – major stroke
• Burn patients
• Any patient who can’t maintain an airway, still has gag reflex,- with possibility of successful intubation

6 ps

• Prep
  
• Preoxygenate, sat at 100% (do not bag while patient is under, all sphincters are relaxed)
• Pretreat (medicating)
  • LOAD
    • Lidocaine – 1-1.5 mg/kg (suppress gag reflex – gag can increase ICP)
    • (Opiods – Fentanyl 3mcg/kg IV – decrease sympathetic response – also for AA or ICP)
      
    • Atropine –0.02 mg/kg – decreases parasympathetic response (also decreases brady affect of Succinylcholine- especially peds)
    • (Defasiculating dose – 10% of normal dose (non-depolarizing) – 2-5 minutes before Succinylcholine)(
      Vecuronium 0.1mg/kg) -
      

       

• Induction (sedation)
  
  • Etomidate – 0.3 mg/kg
    • Rapid onset – 15-45 sec
    • Short duration – 3-12 min
  • Midazolam (Versed) – 0.1-0.3 mg/kg – usual dose is 2 mg because causes hypotension
    • 30-60 sec onset
    • 15-30 minute duration
    • Amnesic effects
• Paralysis (not performed in NYS by paramedics)
  
  • Bind to ACH nicotinic receptors
  • Depolarizing
    • Succinylcholine (sux) – binds to Ach receptors blocking contraction of muscle
    • 1-2mg/kg – max 150mg
    • Peds 1-1.5mg/kg
      • Hyperkalemia (renal problems, significant muscle damage, burn patients, )
      • Bradycardia
      • Dysrythmias
      • hypertension
  • Non-depolarizing
    • Do not cause fasciculations
    • Longer onset
    • Longer action
  • Paralyzed patient has no definitive airway
  • Must be ventilated manually throughout duration of paralysis
  • No affect on mental status – MUST sedate
• Placement of tube
  
• Post intubation management