Leon County EMS RSI Education update 2017

2. Level: Specially Trained EMT-P, RN
“ Airway management can occur without RSI, but RSI cannot occur
without airway management!”
Good patient assessment and proper preparation for airway
management will lead to more effective utilization of skills and better
patient outcomes.

3. Indications:
 Any medical, traumatic, or neurological condition, acute or chronic in
which there is failure to protect the airway.
 Significant altered mental status (GCS ≤ 8) with airway compromise.
 Risk for impending or actual airway compromise in suspected or
anticipated, such as acute burn injury, or acute severe angioedema of
the airway (Airway management should be considered early in these
patients and always be prepared move to Failed Airway Algorithm and
potential Surgical Cricothyrotomy )
 Any condition where there is a failure to oxygenate and or ventilate
and patient has intact gag reflex.

4. Relative Contraindications:
The benefit of obtaining airway control must always be weighed against the risk of
complications in these patients. The following contraindications should be
considered prior to RSI.
o Prediction of Difficult Airway Management
 Lemons
 Moans
 Rods
Short
o Unstable Fractures
o Known Hypersensitivity to any of the drugs involved or history of Malignant
Hyperthermia
 Remember obtaining history from patient in severe respiratory distress or severe
head injury may be difficult or even impossible, search for a reliable source of
information during your assessment.

5. Malignant Hyperthermia
Malignant hyperthermia (MH) is an inherited disorder of skeletal
muscle that can be pharmacologically triggered to produce a
potentially fatal combination of hypermetabolism, muscle
rigidity and muscle breakdown. This is often triggered by
inhaled anaesthetics and the use of Succinylcholine.
Dantrolene is the most common medication used in the
treatment of MH and early recognition of MH is the key to good
patient outcomes.

6. Relative Contraindications Cont:
Additional contraindications associated with succinylcholine admin.
(Consider using nondepolarizing agent instead)
 History of Neuromuscular disease (ALS, MS, Muscular dystrophy,
Myasthenia Gravis) or patients with chronic muscle contractures
 Renal Failure patients with evidence of Hyperkalemia on EKG
 Known Hyperkalemia Patients (K>5.5 mEq/liter)
 Burn Patient greater than 5 days
 Stroke and Spinal Cord Injury 5 days until 6 months
 Intra- abdominal Sepsis greater than 5 days

7. Succinylcholine
As shown in the diagram when Succinylcholine is given, it opens the pathways in
the cells releasing potassium out of the cell into the vascular space. This is the
reason that it should be used cautiously with any person with known or
suspected hyperkalemia.

8. Use NON-Fasciculating agent (ie: Rocuronium) on
patients at risk for or having problems related to:
Hyperkalemia (elevated potassium). Only if EKG Changes
show peaked T waves or wide QRS.
Penetrating eye injuries (do not use depolarizing blocker).
 History of malignant hyperthermia.
Unstable fractures (secondary to muscle fasciculation).

9. COMPLICATIONS ASSOCIATED WITH INTUBATION
Increased intragastric pressure (emesis).
 Bradycardia/asystole (especially in children less than 1 yr not premedicated
with Atropine.)
 Malignant hyperthermia.
 Prolonged apnea.
 Inability to intubate/ventilate after paralytic administration.
 Hypotension.
 Aspiration.
 Dysrhythmias.
 Fasciculations.
 Histamine flush
 Tachycardia.
 Hyperkalemia.
 Inability to recognize decreased neurologic status.
 Bronchospasm

10. USE THE FOLLOWING TO DETERMINE DIFFICULT AIRWAY:
LEMON (Predicts difficult laryngoscopy).
MOANS (Predicts difficult mask ventilation).
RODS (Predicts difficult EGD).
SHORT (Predicts difficult cricothyrotomy).

11. LEMON (Difficult Laryngoscopy)
Look externally
Evaluate 3 – 3 – 2 rule
Mallampati
Obstruction/Obesity
Neck mobility

12. MOANS (Difficult Mask Vent)
Mask Seal
Obese
Aged (> 55 years old)
No teeth
Stiff (increased ventilatory pressures, e.g. asthma, COPD,
ARDS,term pregnancy)

13. RODS (Difficult EGD)
Restricted mouth opening
Obese
Distorted airway
Stiff as in MOANS

14. SHORT (Difficult Cricothyrotomy)
Surgery (previous)
Hematoma
Obese
Radiation
Tumor

15. Preparation
Assemble necessary equipment:
 BVM with correct sized mask
 Working suction equipment
 Appropriate sized ET tubes
 Working laryngoscope
 Appropriate drugs drawn up in syringes
Pulse oximeter
 End-tidal CO2 monitoring device
Have Cricothyrotomy equipment readily available.

16. Preparation cont.
 Assess patient for possible difficult intubation via LEMON, MOANS,
RODS, and SHORT.
 If there is a potential for a difficult airway, go to the Difficult
Airway Algorithm PAGE 488.
 Position patient properly in sniffing position or use in-line
stabilization if indicated.
 Assure at least one secure well running IV line.
 Connect patient to cardiac monitor and pulse oximeter.
 Assign specific duties to personnel on scene (i.e., assistance with
bagging, pushing of medications.)

17. Pre-Oxygenation
Place patient on continuous oxygen via nasal cannula at 6 lpm.
Once the patient is sedated and/or paralyzed, increase the flow
rate to 15 lpm via nasal cannula. Continue nasal cannula
oxygen throughout your intubation attempt while patient is
paralyzed. This is commonly referred to as Passive
Oxygenation
Pre-oxygenate for three minutes via BVM (leave nasal cannula
in place until patient is intubated). This establishes oxygen
reservoir:
 Flushes out nitrogen
 Increases functional residual capacity of lung.
Once intubated, discontinue the nasal oxygen.
When adequately preoxygenated, a healthy 70 kg adult can
remain apneic for up to 6-8 minutes.
Children experience oxygen desaturation more quickly due to
their fast metabolism.
Obese patients experience oxygen desaturation more quickly
due to adipose tissue metabolizing faster.

18. Pre-Treatment
Pre-medicate as appropriate:
Lidocaine 1.5 mg/kg IVP 2 - 3 minutes before intubation:
For possible head injury patients, to mitigate increased intracranial
pressure (ICP) which may occur during intubation.
For patients with reactive airway disease, i.e. severe asthma.
For dysrhythmia control in patients at risk for ventricular
dysrhythmias.
NOTE: Lidocaine is contraindicated if there is known hypersensitivity
to the drug.

19. Pre-Treatment cont.
Fentanyl 3 mcg/kg (~200 mcg IV in average adult) Given as the last pre-
treatment drug. Administer over 30 – 60 seconds.
 Fentanyl is indicated in patients for the potential for increased
intracranial pressure It is used to decrease or block the
sympathetic response during intubation . DO NOT use Fentanyl
on children under the age of 10 during premedication.
Atropine 0.02mg/kg/IV (max 1 mg) – for children less than 12 months
receiving Succinylcholine for RSI.

20. Paralysis with Induction
Induce with ONE of the following:
Amidate (Etomidate) 0.3 mg/kg IV push for sedation.
NEVER REPEAT ETOMIDATE- NEVER REPEAT ETOMIDATE- NEVER REPEAT ETOMIDATE
Versed 0.10 - 0.15 mg/kg IVP for awake patients to achieve amnestic
effect. Pediatric dosage is 0.03 mg/kg.
Versed is contraindicated if the patient is hypotensive.
Alternative drug: Valium 2-10 mg IVP
Ketamine (Ketalar) 1.5 mg/kg IV
First choice if available for reactive airway disease.

21. Paralyze with one of the following:
Anectine (Succinylcholine - depolarizing) 1.5mg/kg IV over 10- 30 sec
NOTE: Onset 30 – 45 seconds.
Duration 4 – 10 minutes.
Rocuronium (Zemuron - non-depolarizing) 1mg/kg IV in adults
Children 0.6mg/kg IV
NOTE: Onset 45 – 60 seconds.
Duration: 20 – 90 minutes.

22. PARALYZE CONT.
Once paralytic has been given IV, discontinue bagging patient with
BVM and monitor pulse ox. It is not necessary to resume bagging
patient until patient is intubated (at which time you ventilate with
ambu-bag via the ET tube) or the oxygen saturation drops below 91%,
at which time you re-oxygenate before trying to intubate again.
Proper pre-oxygenation will allow you 6-8 minutes of allowable apnea
to intubate.
Perform controlled endotracheal intubation with in-line stabilization
if indicated.

23. TECHNIQUE OF ENDOTRACHEAL INTUBATION
Position the patient supine, open the airway.
Open mouth by separating the lips and pulling on upper
jaw with the index finger.
Hold laryngoscope in left hand, insert scope into mouth
with blade directed to right tonsil.
Once right tonsil is reached, sweep the blade to midline
keeping the tongue on the left. This brings epiglottis
into view. “DO NOT LOSE SIGHT OF IT!”
Advance the blade until it reaches the angle between
the base of the tongue and epiglottis (vallecular space).

24. TECHNIQUE OF ENDOTRACHEAL INTUBATION
CONT.
Lift the laryngoscope upwards and away from the nose –
towards the chest. This should bring the vocal cords into
view. It may be necessary for a colleague to press on the
trachea to improve the view of the larynx.
Place the ETT in the right hand, keeping the concave side
of the tube facing the right side of the mouth.
Insert the tube, just so the cuff has passed the vocal cords
and then inflate the cuff.
Using a stethoscope, listen for air entry at both apices
and both axillae to ensure correct placement.

25. Paralyze cont.
Confirm placement by auscultating for bilateral breath sounds,
checking oxygen saturations, and by checking for presence of end-
tidal carbon dioxide (ETCO2) or any three methods in the
confirmation protocol.
If intubation is unsuccessful, remove the tube and ventilate the
patient with 100% oxygen via a BVM until ready to attempt re-
intubation. You should be able to successfully use a BVM to oxygenate
the patient or successfully ventilate until the effects of the paralytic
are gone. Prepare to suction emesis.
Maintain cervical immobilization if necessary.
If after 1-2 repeat intubation attempts fail, go to failed airway
algorithm (4.34 SMART AIRWAY MANAGEMENT), which calls for using
and extra-glottic device or performing a cricothyrotomy. If an extra-
glottic device can be inserted or the patient’s oxygen saturation can
be maintained > 91% with an oral pharyngeal airway and BVM,
transport to hospital.
Only perform a cricothyrotomy if unable to ventilate and unable to
maintain pulse ox > 91%.

26. Post Intubation Management
Once intubation is completed and tube placement is confirmed, inflate the cuff and
continue to ventilate with 100% oxygen via BVM.
Secure ET tube in place.
 Post intubation management should be considered. Continued sedation and pain
management is approved (It is ok to use a narcotic and benzo in combination). If
Ketamine is used for continued sedation it should be used as stand alone not combined
with any other medications in this list.
Ketamine 0.25 to 0.5 mg/kg IV every 5 to 10 min prn
Valium 2-4 mg IV titrate 1mg increments prn
Versed 2.5 – 5 mg IV initial, then titrate 1 mg increments prn
AND/OR
Morphine 2-5 mg IV (for post intubation pain control)
OR
Fentanyl 50 -100 mcq (for post intubation pain control)
Continued paralysis will only be ordered by medical control.

27. Take care not to over sedate your patient, post intubation,
particularly in cases when a neuro assessment will be
necessary upon arrival in the ED. (i.e., cases of head injury
or suspected CVA)

28. Post Intubation Documentation
Proper endotracheal tube placement must be documented by at least three
different methods. These include:
Presence of bilateral breath sounds.
Absence of breath sounds over the epigastrium.
Checking oxygen saturations.
Presence of condensation on the inside of the endotracheal
tube.
End-tidal carbon dioxide monitoring. Must be on All intubated patients
Use of an endotracheal esophageal detector (if available).
Visualizing the tube passing through the cords.
Bilateral, symmetrical expansion of the thorax.
At least three verification methods must be documented in the medical
record!
Remember to record depth of tube as well as what method was used to
secure tube in place in the medical record as.

29. Post Intubation Documentation
Cormack Lehane grading scale can be used to
document the structures seen during
Laryngoscopy. It is graded 1-4 with the grade one
being the best possible glotic view. Comack
Lahane scores directly correlate to Mallampati
scores.
Cormack Lahane Mallampati

30. Considerations:
Once a neuromuscular blocking agent is given, you assume complete
responsibility for maintaining an adequate airway and ventilations.
Have your backup airway (King Airway) available to use if unable to
intubate.
Be prepared to perform a surgical airway if intubation cannot be
executed and ventilation with a BVM is not possible. (This will be rare.)
Continuously monitor oxygen saturations and end-tidal carbon dioxide.
Documentation of confirmation of proper tube placement should be
placed in the medical record every time the patient is moved.