Rapid Intubation
Erica CorraoOct. 19, 2012Health Education for Allied HealthYoungstown State University
What is Rapid Intubation
The cornerstone for emergency airway management
Results in rapid unconsciousness and paralysis in a patient
Considered a crash airway
Indications
Inability to maintain airway patency
Inability to protect the airway against aspiration
Ventilatory compromise
Failure to adequately oxygenate pulmonary capillary blood
Anticipation of a deteriorating course that will eventually lead to the inability to maintain airway patency or protection
Goal
To intubate the trachea without having to use bag-valve-mask ventilation
Without using sedative agents alone
Administration of weight-based doses of an induction agent immediately followed by a paralytic agent to get the patient unconscious within 1 minute
Contraindications
Absolute- total upper airway obstruction & total loss of facial/oropharyngeal landmarks
Relative- anticipated difficult airway to achieve
Crash airway- when the patient is in an arrest situation, unconscious and apneic
Anesthesia
3 phases of medication administration
Pretreatment, induction, and paralysis
Preoxygenation
Preoxygenation with nonrebreather mask for 5 minutes prior
Allows the patient to maintain blood oxygen saturations during the apneic period of paralysis and allow for more time to intubate
Pretreatment
Used to help the response to larygnoscopy and induction and paralysis
Typically administered 2-3 minutes prior to induction and paralysis
Examples are LOAD (lidocaine, opioid analgesic, atropine, defasciculating agents
Induction
Provide rapid loss of consciousness that helps ease the intubation and avoids psychic harm to the patient
Examples of meds are: Etomidate, Ketamine, Propofol & Midazolam
Paralysis
Need to be administered immediately after the induction agent
Neuromuscular blockade does not provide sedation so administering a right dose of the induction agent is important
Equipment Needed
Laryngoscope
Endotracheal tube
Stylet
10 mL syringe
Suction Catheter
CO2 detector
Oral and Nasal airway
Ambu bag and mask
Positioning
Place patient in sniffing position for adequate visualization. You will need to flex the neck and extend the head
This position helps with visualization of the glottic opening
Technique
PreparationConfirm that equipment is functional
Assess for difficult airway
Establish Intravenous access
Draw up drug and determine sequence
Review contraindications to meds
Attach monitoring equipment
Check endotracheal tube for leak
Ensure function light bulb on laryngoscope blade
Technique
PreoxygenationAdminister 100% oxygen through nonrebreather mask for 5 minutes for nitrogen washout
Assist ventilation with bag-valve-mask system only if needed to keep oxygen saturations greater than or equal to 90%
Technique
PretreatmentSee Anesthesia slide for more information
Consider administration of drugs to mitigate the adverse effects of intubation
Technique
Induction of ParalysisGive a rapid acting induction medication to produce loss of consciousness
Administer neuromuscular blocking agent immediately after the induction agent
Should be given by intravenous push
Technique
Protection and PositioningProvide cricoid cartilage pressure
Maintain pressure until ETT is verified in position
Technique
Placement with ProofVisualize the ET tube passing through vocal cords
Confirm tube placement with a color change by CO2 dector and auscultation
Technique
Postintubation ManagementSecure ET tube in place
Initiate mechanical ventilator
Obtain chest x-ray
Administer proper meds for patient comfort and other factors
Complications
Esophageal intubation
Iatrogenic induction of an obstructive airway
Right mainstem intubation
Pneumothorax
Dental trauma
Postintubation pneumonia
Complications
Vocal cord avulsion
Failure to intubate
Hypotension
Aspiration
Conclusion
Rapid Sequence Intubation (RSI) is the preferred technique in emergency departments.
It is not indicated in a patient who is unconscious and apneic.
Approach with caution in a difficult airway
Proper technique is key
Reference
Rapid Sequence IntubationMedscape Reference
medicine.medscape.com/article/80222-overview
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