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RSI• Definition: Using drugs that make emergent intubation of conscious patients safer and more controlled• Process: Use of a sedative /hypnotic agent to induce relaxation/sleepiness/amnesia followed by a neuromuscular blocker to stop any resistance to the intubation process
The Seven Ps of RSI• Preparation• Preoxygenation• Pre treatment• Paralysis• Protection and Positioning• Placement with Proof• Post intubation management
Preparation• Cardiac Monitor, O2 sat, IV access, BP monitor• Suction, all meds ready and drawn up, crash cart, bag valve mask• Difficult airway assessment and alternate airways available
Pre-oxygenation• Done to avoid using Bag Valve mask ventilation• High flow O2 (usually at least 3-5 minutes) given to “wash out” nitrogen and increases body oxygen stores. Can extend time allowed without ventilation for several minutes
Pretreatment• In some cases, Lidocaine 1mg/kg IV or Fentanyl is given to reduce the physiologic increase in ICP in patients with head injuries
Paralysis and Induction• RSI is designed to achieve paralytic and sedated state within one minute. No titration- use whole doses of drugs
Ideal Drugs• Should have duration of very few minutes in case intubation is not successful.• Sedatives used: Etomidate, Midazolam (Versed), Propofol• Paralytics used: Succinylcholine (Anectine)
Sedative Drugs• Etomidate-hemodynamically neutral,• 0.3mg/kg bolus• Midazolam-0.2mg/kg bolus, does often cause hypotension• Propofol-2mg/kg bolus, may cause hypotension and CPP. Bronchodilator
Protection with Positioning• Avoid Bag Mask Ventilation• Cricoid pressure very controversial
Placement with proof• MUST have EtCO2 proof , either colorimetric or quantitative (monitor)• In cardiac arrest may not see CO2 production. Positive CO2 for six breaths is definitive evidence of proper airway placement.• Clinical and CXR evaluation is not definitive for placement
Postintubation Management• Fix the ETT location• CXR for depth of tube• Fluid bolus for transient hypotension