This document discusses rapid sequence intubation (RSI) for airway management in the pre-hospital setting. It outlines the philosophy of RSI, including that it should only be used if absolutely necessary due to risks. The document provides guidance on RSI techniques, medications, equipment, and verification of proper endotracheal tube placement. Several studies are referenced that show risks of RSI including increased mortality rates, hypoxia, and worse outcomes for head injured patients compared to bag-valve-mask ventilation alone. Proper training and only using RSI for prolonged transports are emphasized.

1. Rapid Sequence Intubation Guardian EMS

2. Introduction The most important task in patient care is providing proper support and not further endangering the patient Airway management can be critical in the survival of the patient

3. Introduction Must have the proper (and working) equipment If intubation is initiated, it must be rapid and effective

4. Objectives Philosophy Rapid Sequence Intubation Drugs Rescue and alternatives Verification of placement Current literature

5. Philosophy First, “Do no harm” RSI should only be done if absolutely necessary The paramedic must choose the therapeutic option that offers the most benefit for the least risk

6. Philosophy The first priority in patient care is the Airway (ABC) Rapid airway intervention is critical in certain circumstances, but field RSI has been shown in some large randomized studies to increase mortality of the patient

7. Philosophy If transport times are short (<15 minutes), there are extremely few patients that should be intubated in the field -- use BVM and drive quickly In long transport times, there may be a need to intubate the patient Proper training and maintaining skills are essential

8. The 5 P Philosophy P roper P reparation P revents P oor P erformance

9. Philosophy No equipment, no matter how advanced, is error proof Be prepared for failure Know your equipment and know what you will do when your equipment (or you) fails

10. Patient Protection Protect the patient from intubation that could be harmful Protect the cervical spine (minimize motion) Protect from aspiration Aspiration mortality is 30%-62% Unwatched, obtunded and intoxicated patients can more easily aspirate

11. Scenario Asthmatic patient with severe respiratory distress not responding to nebulizer treatments. The transport time is 30 minutes. The patient is still awake but is becoming confused and tiring.

12. Scenario 25 year-old intoxicated (EtOH) trauma patient on a back board and C-collar. He is deeply sedated with a questionable history of head trauma (starred windshield, patient does not remember accident but is so drunk he can hardly talk at all).

13. Rapid Sequence Intubation Administration of a sedative and a paralytic to facilitate the rapid placement of an endotracheal tube. RSI can help to diminish risk of aspiration

14. EMS RSI Indications Very few Prolonged transport times with high potential for loss of airway or respiratory failure

15. RSI Technique Pre-oxygenate (careful not to bag a conscious or spontaneously breathing patient -- you can inflate the stomach and increase the risk of vomiting) Prepare equipment Pre-medicate Put the patient down (sedate) Paralyze Place tube

16. RSI Equipment Suction Oxygen BVM LMA Working laryngoscope Tubes and stylets Gum Elastic Bougie Bite blocks Tape ETCO2 detectors

17. RSI Timing T-3 min: Ready all equipment, pre-oxygentate T-2 min: Insure IV access T-15 sec: Sedation with etomidate 0.5 mg/kg IVP T-0 sec: Paralyze with succinylcholine 200 mg IVP (1.5 mg/kg)

18. RSI Timing T+10 sec: Sellick’s maneuver T+45 sec: Place tube and verify placement T+5 min: Medications may ware off, add sedation and paralysis as needed

19. Be Prepared Have all of your primary equipment ready and ensure that it works Know what you are going to do with your intubation attempt fails -- have your backup ready to go

20. Pre-medication Lidocaine Used to blunt increases in intracranial and intraoccular pressure for patients with head or eye injuries Dose: 1.5 mg/kg IV over 30-60 seconds

21. Pre-medication Atropine Can help blunt bradycardia in pediatric patients Can help limit secretions Dose: 0.01 mg/kg IVP

22. Sedation Midazolam (Versed) Benzodiazepine with short duration of action May cause hypotension and respiratory suppression Dose for induction: 0.2 mg/kg IVP Dose for maintenance: 0.1 mg/kg IVP

23. Midazolam Most people (including physicians) underdose the midazolam with RSI Use 0.2 mg/kg IVP 70 kg man = 14 mg IVP midazolam

24. Etomidate The best medication for the job Use 0.5 mg/kg IVP Typical dose is 20-40 mg IVP

25. Paralysis Cricoid pressure prior to paralysis and continue until tube is in place Defense against aspiration BURP - Backwards, Upwards, Right Pressure

26. Paralysis Succinylcholine Depolarizing neuromuscular blocker Onset of 30-60 seconds Dose: 200 mg IVP (1.5 mg/kg) -- no danger in “over paralyzing”, but can be hard to intubate if too little is given Precautions: Neuromuscular disease, hyperkalemia, glaucoma, increased gastic pressure

27. RSI If you are going to do it, do it decisively and carefully Be smart about the decision realizing that most data point to increased mortality with field intubations -- egos should never interfere with patient care

28. Rescue and Alternatives Ventilate & retry Gum Elastic Bougie LMA -- limited protection of airway in patient with vomiting Cricothyrotomy

29. Verification You must verify correct tube placement using both clinical exam and mechanical testing

30. Clinical Verification Visualize placement of tube through cords Lung auscultation (bilateral breath sounds) Abdomen auscultation (no gastric sounds with bagging) Clinical improvement Tube condensation (not reliable)

31. Mechanical Verification Pulse oximetry End tidal CO2 detection Esophageal detector device

32. Summary Patient safety and care is top priority Be prepared Minimize aspiration risks Always confirm proper tube placement

33. Literature Avoid thinking that the studies apply to other, less trained medics The medics in many of the studies are well trained and experienced

34. INCIDENCE OF TRANSIENT HYPOXIA AND PULSE RATE REACTIVITY DURING PARAMEDIC RAPID SEQUENCE INTUBATION Dunford, J.V., et al, Ann Emerg Med 42(6):721, December 2003 BACKGROUND: Cerebral injury is exacerbated by hypotension and hypoxia. Outcome studies of prehospital rapid sequence intubation (RSI) in patients with significant head injuries have yielded conflicting results. METHODS: The authors examined data from a subset of 54 adults with closed head injuries who participated in a larger study of paramedic RSI, to identify episodes of desaturation and pulse rate reactivity during RSI. The larger study was performed within the San Diego EMS System and was terminated after it was found that RSI was associated with worse outcomes. The RSI protocol called for preoxygenation for at least 60 seconds, use of midazolam for sedation if systolic pressure was at least 120mm Hg, weight- based dosing of succinylcholine to achieve neuromuscular blockade, and a maximum of three 30-second intubation attempts. RESULTS: Oxygen desaturation during RSI (to levels below 90%, or any decrease in patients having an initial O2 saturation below 90%) was documented in 57% of the patients, most of whom (84%) had initial SPO2 values of at least 90% before administration of RSI medications. The median decrease in SPO2 during desaturation was 22% and the median duration of the episodes was 160 seconds. Most of the patients had a 20-beat increase (61%) or decrease (29%) in pulse rate during desaturation, and 36% developed significant bradycardia (heart rate below 50). The intubation was considered by paramedics to be &quot;easy&quot; in 26 of the 31 RSI episodes associated with oxygen desaturation. CONCLUSIONS: This study demonstrated a substantial rate of oxygen desaturation during RSI by paramedics in patients with serious closed head injury

35. EFFECT OF OUT-OF-HOSPITAL PEDIATRIC ENDOTRACHEAL INTUBATION ON SURVIVAL AND NEUROLOGIC OUTCOME: A CONTROLLED CLINICAL TRIAL Gausche, M., et al, JAMA 283(6):783, February 9, 2000 METHODS: In this extraordinary controlled clinical trial, from Harbor-UCLA Medical Center in Torrance, CA, outcomes were compared in 410 children below the age of twelve who received bag-valve-mask (BVM) ventilatory support in the prehospital setting and 420 similar children who were assigned to receive endotracheal intubation (ETI). Indications for airway management included traumatic or nontraumatic cardiopulmonary or respiratory arrest respiratory failure, airway obstruction, head trauma with nonpurposeful response, or a perceived need for assisted ventilation. All participating paramedics underwent an initial six-hour training course in pediatric airway management. RESULTS Rates of survival to hospital discharge were similar in the ETI and BVM groups (26% and 30%, respectively), as were rates of discharge with good neurologic outcome (20% and 23%). Survival and/or good neurologic outcome were statistically more likely in the BVM group in subgroups having diagnoses of child abuse, respiratory arrest and foreign body aspiration. Overall, ETI was successful in 57 of children in whom it was attempted. Complications specific to ETI included esophageal intubation (2%), recognized or unrecognized dislodgment of the ET tube (14%), mainstem bronchus intubation (18%), and incorrect tube size (24%). Median scene time and total prehospital time were longer (by 2-3 minutes) in the ETI group BACKGROUND: Although pediatric endotracheal intubation is taught in 97% of paramedic training programs and is widely used in the out-of-hospital setting, findings in this landmark study suggest that (in an urban environment) it is no better than, and may be worse than, pre-hospital use of BVM only.

36. THE EFFECT OF PARAMEDIC RAPID SEQUENCE INTUBATION ON OUTCOME IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY Davis, D.P., et al, J Trauma 54:444 March 2003 METHODS: This prospective study, from the University of California, San Diego, investigated the effect of rapid sequence intubation (RSI) on outcomes in adults with severe traumatic brain injury. Paramedics underwent eight hours of training in RSI, GCS scoring and Combitube (CT insertion. Patients were enrolled if they had a suspected head injury with a GCS of 3-8, an estimated transport time of more than 10 minutes, and could not be intubated without RSI. CT insertion was mandated if RSI was unsuccessful. Each of the 209 study patients was matched to three nonintubated historical controls matched for age, gender, trauma center mechanism of injury and abbreviated injury score (AIS) (total controls 627). RESULTS: When compared with controls, the RSI group had a lower rate of &quot;good outcomes,&quot; defined as discharge to home, jail rehabilitation, a psychiatric facility or leaving against medical advice (45.5% vs. 57.9%, p<0.01) and a higher mortality rate (33% vs. 24.2 p<0.05). The RSI group also had longer scene times (mean, 22.8 vs. 16.4 minutes, p<0.0001) and more frequent inadvertent hyperventilation (15.4 vs. 8.0%, p=0.014). Although the measured mean pO2 on arrival at the ED was higher in the RSI group (315 vs. 216mm Hg in controls, p<0.001 transient hypoxia occurred in more than 50% of the intubated patients in whom pulse oximetry was recorded. CONCLUSIONS: In these patients with severe traumatic brain injury, rapid sequence intubation by paramedics was associated with worse outcomes than those documented in unintubated control patients. Since patients were excluded if intubation was unsuccessful, the detrimental effect of RSI might have been underestimated.

37. COMPARISON OF DIFFERENT AIRWAY MANAGEMENT STRATEGIES TO VENTILATE APNEIC NONPREOXYGENATED PATIENTS Dorges, V., et al, Crit Care Med 31(3):800, 2003 BACKGROUND: Although endotracheal intubation is considered the gold standard for emergency airway management, adjunctive techniques can sometimes be necessary. METHODS: This German study evaluated alternative strategies for emergency ventilation in an apneic patient. Forty-eight ASA I/II non-preoxygenated adults undergoing general anesthesia for a routine surgical procedure were randomized to use of one of four airway devices (bag-valve-mask [BVM], laryngeal mask airway [LMA], cuffed oropharyngeal airway [COPA] or Combitube [CT]). The devices were inserted by an experienced paramedic, and patients were ventilated with 100% oxygen for three minutes, using a self-inflating pediatric bag. RESULTS: The study was terminated due to a decrease in oxygen saturation below 90% during insertion in 3/12 patients in the COPA group, 2/12 in the LMA group and 1/12 CT patients; this complication did not occur in the BVM group Achievement of adequate tidal volumes was also accomplished more rapidly in the BVM group (20 vs. 33-43 seconds). Oxygen saturation decreased statistically during insertion of the CT and LMA, but not with the BVM or COPA. In all patients, however, O2 saturation increased to greater than 98% after one minute of ventilation with 100% oxygen. CONCLUSIONS: Bag valve-mask ventilation with a pediatric self-inflating bag and 100% oxygen appeared to be the most simple and effective of four airway strategies in this series of non-preoxygenated apneic adults ventilated in the operating room by paramedics.

38. COMPARISON OF DIFFERENT AIRWAY MANAGEMENT STRATEGIES TO VENTILATE APNEIC NONPREOXYGENATED PATIENTS Dorges, V., et al, Crit Care Med 31(3):800, 2003 BACKGROUND: Although endotracheal intubation is considered the gold standard for emergency airway management, adjunctive techniques can sometimes be necessary. METHODS: This German study evaluated alternative strategies for emergency ventilation in an apneic patient. Forty-eight ASA I/II non-preoxygenated adults undergoing general anesthesia for a routine surgical procedure were randomized to use of one of four airway devices (bag-valve-mask [BVM], laryngeal mask airway [LMA], cuffed oropharyngeal airway [COPA] or Combitube [CT]). The devices were inserted by an experienced paramedic, and patients were ventilated with 100% oxygen for three minutes, using a self-inflating pediatric bag. RESULTS: The study was terminated due to a decrease in oxygen saturation below 90% during insertion in 3/12 patients in the COPA group, 2/12 in the LMA group and 1/12 CT patients; this complication did not occur in the BVM group Achievement of adequate tidal volumes was also accomplished more rapidly in the BVM group (20 vs. 33-43 seconds). Oxygen saturation decreased statistically during insertion of the CT and LMA, but not with the BVM or COPA. In all patients, however, O2 saturation increased to greater than 98% after one minute of ventilation with 100% oxygen. CONCLUSIONS: Bag valve-mask ventilation with a pediatric self-inflating bag and 100% oxygen appeared to be the most simple and effective of four airway strategies in this series of non-preoxygenated apneic adults ventilated in the operating room by paramedics.