1-6. Rapid Sequence Intubation
“RSI” or Paralytic Assisted Tracheal Intubation “PATI”
1-6-a. Indications
1) Inability to maintain oxygen saturation > 90% by any other more conventional means;
2) Inadequate ventilation; and,
3) Unable to protect airway.
As much as possible, hyper-oxygenation should be attempted pre-RSI, by administering high flow O2 by mask, and also by doing apneic oxygenation via nasal prongs at 15 LPM before and during RSI.
1-6-b. Preparation
1) Start / increase pre-oxygenation.
2) Assure suction is available and set up.
3) Establish and secure an IV or an IO.
4) Place cardiac monitor and POX on patient.
5) Prepare waveform capnography.
6) Ready intubation equipment and supplies.
7) Setup alternate airway adjuncts: SGA and BVM.
8) Restrain patient, as appropriate.
1-6-c. Medication and RSI perform these steps, in this order
1) Preoxygenate.
2) Administer Etomidate 0.3 mg/kg up to a max dose of 30 mg IV/IO.
3) If X Etomidate give Midazolam 0.1 mg/kg up to a maximum single dose of 10 mg IV/IO.
You may repeat the Midazolam 0.1 mg/kg if it is needed to a maximum total dose of 0.3 mg/kg.
4) Support ventilation to the extent needed after giving sedation, using BVM with attached supplemental high flow O2.
5) Administer Succinylcholine 1.5 mg/kg IV/IO up to a maximum single dose of 200 mg.
6) Apply backward, upward, rightward pressure to larynx (BURP maneuver) to facilitate intubation.
7) Intubate and assess ET tube placement.
8) Secure ET tube position and reassess tube placement.
9) Monitor continuous waveform capnography/EtCO2 to ensure ongoing correct tube placement.
10)Administer additional Midazolam, or add Midazolam after Etomidate, as needed for continued patient sedation up to a total of 0.3 mg/kg.
11)Any sedation should be administered by slow IV push.
12)If relaxation is inadequate to allow intubation after 1-2 minutes, recheck IV quality. If needed, start a new IV/IO, then repeat the same dose of Succinylcholine and sedation, and re-attempt tracheal intubation.
13)If unable to intubate the paralyzed patient, insert SGA.
14)If unable to insert SGA, use BVM assisted ventilation with maximal attention to technique.
15)Ventilation optimal rates: When bagging the intubated patient and/or setting the ventilator rate, consider the clinical situation pre-intubation and pick a respiratory rate that is appropriate.
a) Normal = 12 /minute with a tidal volume of 8 cc/kg;
b) Asthma = Slow, 8 /minute with a tidal volume of 6 cc/kg; and,
c) Acidosis = Fast, 20 /minute with a tidal volume of 8 cc/kg.
