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New Hampshire Division of Fire Standards & Training and Emergency Medical Services
What is RSI ?
RSI Assistant
Why RSI Assistants? Required as part of 2009 NHEMS Patient Care Protocol 5.4 RSI RSI Assistant retraining required every two years 2009 NHEMS Rapid Sequence Intubation (RSI) Protocol 5.4 This procedure is only to be used by paramedics that are trained and credentialed to perform RSI by NH Bureau of EMS. Either 2 RSI paramedics or 1 RSI paramedic and 1 RSI assistant must be present.
3. 4.
Assist an RSI certified provider during RSI emergency airway procedures. Be familiar and practiced with all basic and advanced airway equipment/adjuncts maintained on EMS unit. Be competent in basic airway management. Be familiar and practiced with rescue airways maintained on EMS unit.
5.
RSI Indication
Immediate, severe airway compromise in the context of trauma, drug overdose, status epilepticus, etc., where respiratory arrest is imminent.
Basically, RSI is considered for patients requiring advanced airway management who would not tolerate awake intubations.
Patients requiring oxygenation/ventilation management and or positive pressure ventilation: Such as, Traumatic brain injury with ALOC Severe thoracic trauma (flail chest, pulmonary contusions with hypoxemia) Clinical condition expected to deteriorate Unconscious or ALOC with potential for or actual airway compromise or vomiting And patient has A clenched jaw An active gag reflex
Contraindications
As determined by RSI Provider As per NHEMS Protocol 5.4 Extensive recent burns or crush injuries greater than 24 hours old. History of Malignant Hyperthermia Too risky, based on a Risk/Benefit Analysis performed by RSI provider.
Complications
Increased intracranial pressure Increased intraocular pressure Increased intragastric pressure Aspiration due to decreased gag reflex Malignant hyperthermia Dysrhythmias Hypoxemia Airway trauma Failure to intubate / failure to ventilate DEATH
1. Preparation
A two-part process:
RSI assistants
Must be familiar with the RSI procedure and all necessary airway equipment
1. Preparation
RSI Assistants should as directed prepare the following equipment: Basic adjuncts Suction Adult BVM with O2 Source ETT equipment as requested by RSI Provider Alternative airways accessible and ready Combitube, EasyTube, LMA, King, and Commercial Trach Device ETT placement confirmation devices Capnography
How does the RSI Provider know if the patient is going to be difficult to intubate
C-spine immobilized trauma patient Protruding tongue Short, thick neck Prominent upper incisors (buckteeth) Receding mandible High, arched palate Beard or facial hair
Dentures Limited jaw opening Limited cervical mobility Upper airway conditions Face, neck, or oral trauma Laryngeal trauma Airway edema or obstruction Morbidly obese
Objectives
RSI Providers use the following mnemonics to help predict a difficult airway:
LEMONS
Look
Externally Evaluate 3-3-2 Mallampati Score Obstruction Neck Mobility Scene and Situation
LEMONS
Difficult Cricothyrotomy
Performed by RSI Provider DOA Disruption or Distortion Obstruction Access Problems If you cant bag and cant cric, theyre DOA
Do you have a reasonable chance to get the tube? Space, positioning, access
Egress
RSI Assistant
If endotracheal intubation proves difficult or fails for the RSI Provider. BE PERPARED Have Basic Adjuncts and BVM ready
Plans A, B, and C Know the answers before you begin Role of RSI Assistant
Plan A: (ALTERNATIVES)
Different:
Hockey stick bend in ETT or Directional tip ETT Gum Elastic Bougie or Flex-guide Endotracheal Tube Introducer Remove the stylette as you pass through the cords BURP (aka ELM) 2-person technique
cowboy or skyhook
The assistant should be able to identify and prepare the devices for the advanced provider, if asked.
BURP Maneuver
While the RSI assistant is applying the Sellick maneuver, the RSI Provider may ask for:
Manipulate the trachea by pushing directly posterior and up to the patients right. The RSI Provider will be sweeping the oral anatomy to the patients left with a laryngoscope. This simple procedure will increase the RSI Provider chance of successfully placing the tube.
Last resort
The assistant should be able to identify and help prepare the cricothyrotomy devices for the advanced provider, if asked.
1. Preparation
A two-part process:
Equipment is present, opened and ready for use Adequate Ambu-mask/oxygen sources/suction 2 laryngoscope handles Assortment of blades Assortment of ET tubes, stylette, syringe RSI Assistant
1-2 secure IV lines All pharmaceutical agents needed for the procedure Back-up plan and rescue airway devices Oximetry and capnography monitoring Bulb-style tube checker If appropriate, explain procedure to patient
Cardiac monitor
Pulse oximeter
Waveform Capnography
2. Preoxygenation
Preoxygenation
Pre-oxygenate with 100% O2 via nonrebreather mask for at least 3-5 minutes
Replaces the patients functional residual capacity (FRC) of the lung with oxygen
Nitrogen Washout
If done properly, this will permit as much as 3-4 minutes of apnea before hypoxia develops
In emergent cases, eight mask breaths with 100% oxygen may have to suffice.
Assistant: You will most likely be responsible for the preoxygenation of your patient.
2. Preoxygenation
Preoxygenation
Resist the use of positive pressure ventilation (PPV). Use only if the patient is not ventilating adequately. PPV leads to gastric distention regurgitation aspiration If PPV is necessary, utilize cricoid pressure Place NG/OG if prolonged use of BVM Little known fact: Aspirating a few CCs gastric contents increases the patients risk of death. Did we say cricoid pressure?
4. Paralyze
Cricoid Pressure
Begin just as Etomidate is administered Maintained until ETT placement is confirmed and tube is secure (cuff inflated) Used to occlude the esophagus and prevent passive regurgitation common with Succs
4. Paralyze
Cricoid Pressure
Use thumb and forefinger to apply pressure directly backward/posterior over the cricoid cartilage.
Medications are ONLY to be drawn, prepared, and administered by the Paramedic RSI Provider. The Basic or Intermediate Assistance cannot prepare RSI Medications, as they are not licensed or credentialed for their use.
3. Premedication
Lidocaine
Why: May prevent a rise in intracranial pressure in traumatic brain injured patients. When: At least minutes prior to intubation
3. Premedication
Atropine
4. Paralyze
Etomidate
No analgesic properties
4. Paralyze
Succinylcholine
Why: Relaxes the patients muscles enabling the paramedic to intubate the patient.
Assistant: You will likely see the patient go through a brief period of fasciculation followed by complete flaccidity, as the patient becomes paralyzed.
4. Paralyze
Fasciculations
Muscular twitching involving the simultaneous contraction of contiguous groups of muscle fibers
Merriam-Webster Dictionary
4. Paralyze
Paralyze
Induction medications administered by RSI provider Cricoid Pressure, provided by RSI Assistant
Intubation is performed when there is full relaxation of the airway muscles About 90 seconds after Succinylcholine If intubation fails, maintain cricoid pressure and ventilate with BVM After patient is reoxygenated, reattempt or move to a different airway adjunct
Assistant: You are still performing the cricoid pressure at this point.
COMPLICATIONS:
Ventilate with BVM / high flow O2 with cricoid pressure maintained They may make ONE more attempt to intubate If still unsuccessful continue BVM / Cricoid pressure Secure Airway with backup device (CombiTube, LMA or King-LT-D)
Assistant: The advanced provider may ask you to perform the BURP maneuver to better visualize the cords.
If ETT Unsuccessful
If unable to intubate, unable to secure the airway with backup device, and unable to maintain an SpO2 of >90% with a BVM RSI Provider should contact Med Control The medications administered by the RSI Provider to facilitate intubation will wear off in several minutes.
6. Proof of Placement
Proof of Placement
BEST
SUBJECTIVE Absence of abdominal sounds while ambubagged Mist in the tube Bilateral breath sounds Rise/fall in chest
Self-inflating bulb Confirm placement using at least 3 methods, including capnography waveform.
Assistant: Be familiar with the set-up and/or assembly of the various confirmation devices as you will likely be called upon to connect them.
6. Proof of Placement
Provides quick estimate of PaO2 Often referred to as an additional vital sign Non-invasive
6. Proof of Placement
Waveform Capnometry
Number of important applications Monitor & Confirm ETT placement Useful to document adequacy of ventilation during mechanical ventilation Limitations: For patients with impaired pulmonary function or hemodynamic instability
Assistant: Become familiar with the appropriate waveform for a properly ventilated patient.
6. Proof of Placement
Waveform Capnometry
Prerequisite Requirement Becoming a standard of care Easy to Use Good measure of Pulmonary Perfusion Relates well to PaCO2 Does have limitations
6. Proof of Placement
The Capnogram
A to D D to E
Inhalation
6. Proof of Placement
RSI assistant should secure airway device with commercial device Immobilize the head with a cervical collar RSI provider must verify correct placement each time the patient is moved Continue to monitor Waveform capnography SpO2 Vital Signs Patients LOC
Sedation Assessment
Sign/symptoms
Movement Increase in heart rate Increase in blood pressure Decrease in SpO2 Changes in muscle tone Facial muscle tension
Assistant: Pay close attention to the patients level of consciousness. Should the patient at anytime show any of these signs/symptoms of discomfort inform the advanced provider immediately!
Induction Agent,
Paralytic
Time +1 minutes
Intubation
Medication Sequence
Oxygen Lidocaine and/or Atropine if indicated Etomidate Cricoid Pressure Succinylcholine INTUBATION Lorazepam prn Rocuronium or Vecuronium prn
BVM Gum Elastic Bougie Laryngeal Mask Airway (LMA) Esophageal Tracheal Combitube King-LT-D Become familiar with the rescue airway carried on your EMS unit.
Assistant: Be familiar with the set-up and/or assembly of the various backup devices as you will likely be called upon to assist with them.
BVM
Can you obtain a good mask seal? Adequate chest rise & fall? Adequate oxygenation & ventilation?
LMA
Good temporizing measure Multiple sizes Aspiration likely if vomiting occurs Pre-Hospital use unproven/unpublished
Risk of aspiration
Combitube
Especially
suited for
Patients with difficult anatomy Reduced access spaces Reduced illumination (bright light)
King-LT-D
Unable to intubate (including blind rescue devices) and unable to ventilate with a BVM and maintain an Sp02 > 90 %.
Cricothyrotomy
RSI Providers last resort for airway control Low frequency/high risk skill Can be complex and confound decisions
In all cases of a failed airway, the operator must continually assess the adequacy of oxygenation and ventilation 7% of all trauma patients will require intubation
Always weigh the risks and benefits of intubation in the prehospital setting against transport to the ED. In many circumstances, rapid transport might be the best way of managing the airway.
Manual of Emergency Airway Management
Do No Harm
Master bag-and-mask ventilation. There are very few airway emergencies in the prehospital setting that will not be temporized or managed adequately with proper bag-and-mask ventilation until the patient can be transported to the hospital.
Manual of Emergency Airway Management
Documentation Required
Responsibility of the RSI Provider EMS Agency and Resource Hospital Medical Director are required to CQI/QA 100% of prehospital RSIs
Case Studies
Case 1
67 y/o female code blue in asystole. RSI or not??? PLAN?
Case 2
72 y/o female with Hx fever, productive cough and progressive dyspnea. Lethargic, perioral cyanosis. RR 34 and labored, HR 114, BP 117/76. Lung sounds equal with scattered rhonchi. RSI or not??? PLAN?
Case 3
41 y/o female with c/o asthma attacks x20 minutes. Severe respiratory distress. RR 32, HR 127, BP 160/92. Bilateral I/E wheezes. Within 10 minutes, she becomes lethargic and her RR slows. RSI or not?? PLAN?
Case 4
46 y/o male with a Hx of EtOH and drug abuse. Presents with had a seizure per bystanders. Pt is responsive to pain, but does not follow commands or answer questions. RR 18, HR 109, BP 120/80. Within minutes, he has 2 episodes of vomiting and gurgling respirations. PLAN?
Case 5
25 y/o male with GSW to abdomen. Pt is intoxicated, decreased LOC, minimal gag reflex. RR 8-10, HR 120, BP 100/80. PLAN?
Case 6
87 y/o male MVC, high-speed, unrestrained. Patient gasping for air, able to talk, c/o right side CP. RR 32, HR 120, BP 186/92. Multiple deformities to face and chin. Ecchymosis and swelling to neck and anterior chest. Large flail segment to ant/lat chest. Decreased BS on the right. No stridor, but some gurgling in throat. PLAN?
References
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright 2002 Mosby, Inc. Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier Roberts: Clinical Procedures in Emergency Medicine, 4th ed., Copyright 2004 Elsevier