TRAUMA AND EMERGENCY

CARE
RAPID SEQUENCE INTUBATION
• Is a specialized form of placing and endotracheal tube (ETT) in a patient to
provide ventilation via a secure airway.

• Candidates for RSI:

1. Patients in respiratory distress
2. Patients unable to maintain a patent airway
3. Patients with potential for gastric content regurgitation

• An RSI is designed to ensure that no gastric contents are aspirated into the
tracheal tree.
Clinical Technique
• RSI differs from normal intubation in several key ways. All intubations
requires preoxygenation to fill the functional residual capacity (FRC)
with 100% oxygen:
1. RSI calls for those of the Sellick Maneuver (cricoid pressure) while
the patient is induced with anesthetic medications.
Sellick Maneuver (Cricoid Pressure)
• Cricoid cartilage is the first tracheal cartilage ring below the larynx. It is located near the middle and center of the neck.
• Application of pressure results in compression of the esophagus that helps prevent the chances of gastric content regurgitation.
• Complications:
 Interference with tracheal intubation
 Esophageal rupture
 Fracture
• Once pressure to the cricoid cartilage is applied, it is not removed until placement of ETT has been confirmed by end-tidal carbon
dioxide (ETCO₂) and bilateral breath sounds.
• When is the best time to apply cricoid pressure?
 Before administering any medication
 Immediately after the patient loses consciousness
 Excessive pressure is quite uncomfortable in an awake patient.
 Reassure patient by explaining the procedure, actions and goals.
Clinical Technique
• Once induced the patients with RSI is not ventilated before
administering neuromuscular-blocking agents or before attempting
direct laryngoscopy.
• A period of apnea is intentionally instituted to prevent forcing air into
the stomach via positive-pressure ventilation.
During normal intubation, at least one attempt is made at controlled
positive-pressure mask ventilation (test breath) between the
administration of the anesthetic induction agent and the
neuromuscular-blocking agent.
The major risk for RSI is the inability to ventilate the patient should
intubation fail.
Clinical Technique
2. Assembly of all required equipment is essential before attempting
any intubation.
Suction – to remove secretions, blood, and regurgitate materials.
One or more laryngoscope handles with charged batteries
At least 2 laryngoscope blades
Macintosh Blades
Multiple sizes of ETT

Miller
Any method of delivering positive-pressure ventilation Blades

A patent IV line
COMMON ENDOTRACHEAL TUBE SIZES
AGE AND SEX APPROPRIATE SIZES MOST COMMON SIZE DEPTH OF INSERTION AS
MEASURED AT TEETH
CHILDREN AGE/4 + 4 (AGE =16/4+4) VARIABLE AGE + 10cm
ADULT MEN 7.5-8.5 8.0 23cm
ADULT WOMEN 6.5-7.5 7.0 21cm

The endotracheal tubes size (“give me a 6.0 tube”) refers to its internal diameter in millimeters (mm)

The narrower the tube, the greater resistance to gas flow

Clinical Technique
3. If the patient is alert and cooperative, administer 30ml of sodium citrate to
decrease the acidity of the stomach content. If time permits, 50 mg of IV ranitidine
(Zantac) or 10mg of IV metoclopramide (Reglan) may be admistered to decrease
the risks involved with regurgitation and aspiration.
4. Preoxygenation is recommended before attempting intubation of any patient.
Both obesity and pregnancy can significantly reduce the physical volume of the
FRC. Both further decreases FRC upon induction of anesthesia due to the
cephalad movement of the diaphragm.
Tachycardia, sepsis, and other hyperdynamic states causes a more rapid use of
the oxygen in the FRC.
Potential patients who may have lost their normal protective airway reflexes
pose a unique problem. In this case, the practitioner may skip preoxygenation
and establish controlled airway via immediate tracheal intubation.
Clinical Technique
5. Once preoxygenation is completed and cricoid pressure is applied, an
appropriate induction drug is administered, followed by
neuromuscular-blocking agent that is almost immediately
administered.
• Drug allergies
• Watch out for signs of hyperkalemia (Anectine)
• Assess respiratory status continuously
• Monitor HR and BP
COMMON MEDICATIONS USED IN RAPID
SEQUENCE INTUBATION
MEDICATIONS USES DOSES (mg/kg) ADVANTAGES CONSIDERATIONS
SODIUM THIOPENTAL Induction of anesthesia 4-6 Rapid onset, short duration Hypotension, apnea
(Pentothal)
Etomidate (Amidate) Induction of anesthesia 0.2-0.3 Rapid onset, short duration, Myoclonus
cardiovascular stable, may
allow spontaneous ventilation
Porpofol (Diprivan) Induction of anesthesia 2.0-2.5 Rapid onset, short duration Hypotension, apnea

Ketamine (Ketalar) Induction of anesthesia 1.0-2.0 Increased sympathetic tone Tachycardia, increased
bronchodilation sympathetic salivation
Succinylcholine (Anectine) Depolarizing neuromuscular 1.0-1.5 Rapid onset, 5-7 minutes Muscular fasciculations,
blockade duration. Gold standard for RSI hyperkalemia, bradycardia,
and dysrhythmias
Rocuronium (Zemuron) Nondepolarizing 0.9-1.2 Rapid onset; no risk of Extended duration (45-90 min)
neuromuscular blockade hyperkalemia potential for IV precipitation
Vecuronium (Norcuron) Nondepolarizing 0.2 Cardiovascular stable Slow onset (>2-3 min)
neuromascular blockade extended duration (60+ min)
• Most induction medications have an onset of one arm-brain
circulation or about 15 to 20 seconds in patient with normal cardiac
output.
• Usually patients may be safely intubated approximately 1 minute
after administering neuromuscular blocking agents in RSI.
• Meticulous attention to detail, including the proper labeling of the
medications used in the induction and intubation of patients, is
essential
Nursing process
• Assessment:
 History taking
 Examination
 Establish baseline data
 Physical assessment
• Nursing diagnosis:
 Impaired gas exchange
 Impaired verbal communication
 Risk for injury
 Impaired skin integrity
• Intervention
 Prepare emergency equipment for possible mechanical ventilation
 Provide skin care
 Monitor vital signs
 Provide safety measures
 Educate client
6. Intubate patient approximately 1 minute after administering
neuromuscular blocking agent.
7. Verify placement of ETT either BBS or ETCO2. Chest X-ray AP is the
definitive standard.
8. Cricoid pressure may be released only after the ETT placement has
been verified.
PROGNOSIS
• Up to 40% of emergent intubations are unsuccessful on the first
attempt.
• Require some changes in technique, deep suctioning of the
oropharynx may be indicated, using different laryngoscope blade or
repositioning the patient. Cricoid pressure may need to be lessened
but it should never be completely removed
Equipment needed
1. Laryngoscope handles with fresh batteries or a working light source.
2. Multiple laryngoscope blades of various types and length with
working light bulbs.
3. ETTs with various diameter; at least one ETT with an inserted semi-
rigid stylet
4. Suction
5. Induction and paralytic medications.
6. ETCO₂ monitor
7. Gloves
Procedure
1. Preoxygenate the patient (may be omitted if airway reflexes are lost
or if foreign is observed in the oropharynx).
2. Apply cricoid pressure
3. Administer medications.
4. Provide intubation.
5. Check for placement of ETT.
6. Release cricoid pressure.