5. RSI – Rapid Sequence Intubation
RSI is the virtually simultaneous administration of a sedative and a
neuromuscular blocking agent to render a patient rapidly unconscious
and flaccid in order to facilitate emergent endotracheal intubation and to
minimize the risk of aspiration.
6. Advantages of RSI
Facilitates and expedites endotracheal intubation
1. Increase success rate
2. Decreased time for intubation
Minimizes trauma during laryngoscopy
Minimizes hypoxia and hypercapnia
Minimizes risk of aspiration
Minimizes hemodynamic effects of intubation
7. Seven “P” of RSI
1. Preparation
2. Pre oxygenation
3. Pre treatment
4. Paralysis with induction
5. Protection and positioning
6. Placement with proof
7. Post intubation management
8. Preparation
(10 mins before intubation )
Prepare the Patient
Prepare the equipment
Prepare the team
Prepare for difficulty
9.
10.
11.
12.
13.
14. Preoxygenation/De nitrogenation
(5 mins before intubation)
To replace all the nitrogen in the lungs with oxygen prior to intubation
Act as a O2 reservoir during apneic period of RSI
Maximal FiO2 for 3 – 5 mins
Conscious patient 8 full vital capacity breaths
If SpO2 cannot increased > 93% after optimal preoxygenation We can use NPPV or
mask ventilation with a positive end expiratory pressure
16. Pre treatment ( 3 mins before intubation)
Laryngoscopy can activate coughing ang gagging
Infants – Bradycardia
Adults – Pressure response Change in BP , Increase ICP HR, Bronchospasm,
Dysrhythmias
17. Drugs
Glycopyrolate – Anticholinergic decrease secretion and prevent aspiration
Dosage ; 5-10 micrograms / kg
Atropine – Reduce incidence of bradycardia
Dosage ; 0.01 mg/kg or 10 micrograms / kg
Fentanyl – Reduce pressor response and prevent rise in ICP
Dosage ; 2-3 microgram/kg given at a rate of 1-2 microgram/kg/min
Lidocaine – 1.5-2 mg/kg iv over 30-60secs
18. Paralysis with induction
To induce loss of consciousness
Head injury or Stroke
we have to maintain adequate cerebral perfusion and maintain arterial pressure.
1. Etomidate 0.3 mg/kg – Excellent sedation, does not cause hypotension
2. Ketamine 1-2 mg/kg – Hypotensive patient with head injury, Septic shock,
Bronchospasm. Avoid in cerebral hemorrhage
3. Midazolam, Propofol can be used in head injury but risk of hypotension.
19. Paralysis with induction
Status Epilepticus – Midazolam (0.2-0.3mg/kg) can cause hypotension
use etomidate if hemodynamic compromise
do not use ketamine due to stimulant effect
Severe Bronchospasm
Hemodynamically stable – Ketamine, Propofol, Etomidate, Midazolam
Unstable- Ketamine or Etomidate
Cardiovascular – Etomidate
Shock – Etomidate or Ketamine
20. NEUROMUSCULAR BLOCKING AGENTS
PRODUCE PARALYSIS. NOT PROVIDE SEDATION OR ANALGESIA. USED IMMEDIATELY
AFTER INDUCTION AGENTS.
DEPOLARIZING: Succinylcholine (Sch), binds to Ach receptors produces
fasciculation's and paralysis.
NON DEPOLARIZING: Rocuronium, Vecuronium, and Pancuronium. Competitively
inhibit the post- synaptic Ach receptor and produce paralysis.
21. DEPOLARIZING PARALYTICS
SUCCINYLCHOLINE (1-2 mg/kg): Mostly preferred agent due to rapid onset (45-60
sec) and offset (6-10 mins). Better to overdose than under dose.
Absolute Contraindications:
SIGNIFICANT HYPERKALEMIA DEMONSTRATED BY ECG FINDING.
MALIGNANT HYPERTHERMIA (FAMILY OR PERSONAL Hx.)
RHABDOMYOLYSIS
STROKE OR BURN 72 HOUR OLD, DUE TO UPREGULATION OF Ach RECEPTORS
SIGNIFICANT NEUROMUSCULAR Dx OR MUSCULAR DYSTROPHY
22. NONDEPOLARIZING NEUROMUSCULAR BLOCKING
AGENTS (NMBAS)
USED WHEN DEPOLARIZING AGENTS ARE CONTRAINDICATED OR PROLONGED
BLOCKADE IS WARRANTED.
ROCURONIUM (1 mg/kg): Short onset (45-60 sec), duration upto 45 mins. Effect
comparable to Succinylcholine.
VECURONIUM (0.15 mg/kg): onset about 90 sec.
A predicted difficult airway is the most common relative contraindication to
the use of nondepolarizing NMBAs for RSI
23. PROTECTION (CRICOID PRESSURE) AND
POSITIONING
This phase of RSI refers to protecting the airway against aspiration prior to
placement of the endotracheal tube by avoiding bag-mask ventilation and
applying cricoid pressure (Sellick's maneuver). Bag-mask ventilation is
unnecessary if the patient has been successfully preoxygenated.
A common error is to apply pressure to the thyroid cartilage
(Adam's apple).
25. PLACEMENT WITH PROOF
After paralysis has been achieved finally the tube is placed through glottis and cuff
is inflated.
The most accurate means of confirming ETT placement is End-tidal CO2
(EtCO2) determination.
A single-view chest radiograph is only useful to determine depth of placement (eg,
tracheal versus right mainstem).
30. POSTINTUBATION MANAGEMENT
RSI remains incomplete until the properly placed endotracheal tube is secured.
Several techniques are commonly used to secure the tube, including taping, tying
etc.
Hypotension can occur due to decreased venous return from increased
intrathoracic pressure due to mechanical ventilation or due to sedatives.
31. Other Technique
Delayed sequence intubation
Awake oral intubation
Oral intubation without pharmacologic agent
32. Other devices – Video laryngoscopy
Indications;
Routine emergency intubation
Failed DL, Known or Suspected difficult airway
Morbid obesity
Trauma patient with C Spine immobilization
Contraindications;
Limited mouth opening
Severe kyphosis
Copious blood or secretions
Complications;
Dental trauma
Oropharyngeal trauma