Rapid Sequence Intubation

Definition

Administration of potent induction agent after pre-oxygenation followed immediately by rapidly acting neuromuscular blocking agent to induce unconscious and motor paralysis  for tracheal intubation without interposed positive airway ventilation

Indications for intubation

Inability to maintain patent airway/tone	Upper airway sweling, facial/neck trauma, Poor GCS
Ventilatory compromise	Hypoventilation, large pneumothorax, flail chest, Severe COPD, status asthmaticus
Failure to adequately oxygenate	Severe hypoxemia, APO, PE, ARDS
Anticipation of deteriorating course	Severe haemorrhagic shock, ICB with poor GCS, Septic shock

Contraindications

• Total upper airway onstruction
• Total loss of oropharyngeal/ facial landmarks

7 P's

1. Preparation

2. Pre-oxygenation

3. Pre-treatment

4. Paralysis with induction

5. Positioning

6. Placement with proof

7. Post-intubation management

1. Preparation

Patient must be managed in resuscitation area

Prepare yourself, have a skilled assistants

Prepare the equipment- Remember this mnemonic MALES+4S

Mask and Monitoring	•Non-rebreather mask/Bag valve mask •Cardiac monitor, pulse ox, BP cuff opposite arm with IV line
Airway	•Airway adjuncts (e.g. OPA, NPA, LMA) and Ask for difficult airway trolley
Laryngoscope	•Blade – Mac 3 or 4 for adults – curved blade •Miller 3 or 4 for adults – straight blade •Handle – attach blade and make sure light source works
ETT	•7.5 ET tube with stylet fits most adults, 7.0 for smaller females, 8.0 for larger males
Suction	•Immediate suction with a large bore Yankauer suction
Stylet	placed inside ET tube for rigidity, bend it 30 degrees starting at proximal end of cuff (i.e. straight to cuff, then 30 degree bend)
Stethoscope	Use this to listen to air entry and in ryles tube insertion later
Syringe and securing tape	Use syringe to inflate the cuff after successful intubation and tape to anchor the tube

Other suggested mnemonic: MARBLESx2 or SOAP-ME

Assess airway upon patient arrival. Use mnemonic LEMONS

• Look externally- for maxilofacial/neck trauma, beard, obesity, cachexia, edentulous mouth
• Evaluate 3:2:2 rule (3 fingers for mouth opening, 3 fingers between hyoid bone and mentum, 2 fingers between thyroid cartilage and hyoid bone
• Mallampati score- direct peroral pharyngeal visualization and that seen with laryngoscopy.
• Obstruction. Evaluation for stridor, foreign bodies, and other forms of sub- and supraglottic obstruction should be performed in every patient prior to laryngoscopy.
• Neck mobility

2. Preoxygenation

Principle

•establishment of oxygen reservoir within the lung, blood and body tissue to permit several minutes of apnoea without arterial oxygen desaturation

•no bagging principle

•Replacement of predominantly nitrogenous mixture of room air with oxygen allowing several minutes apnea time before Hb saturation <90%

Principle reservoir - functional residual capacity (FRC) ~ 30ml/kg

Method

•Administration of 100% oxygen for 3 minutes,

•or by having the patient take 8 vital capacity breath while on 100% oxygen

3. Pretreatment

Administration of drugs to mitigate adverse effects associated with the intubation or patient's underlying comorbidities.

Adverse effects include

•  Bronchospastic reactive airway
•  Increased ICP
•  Reflex sympathetic response to laryngoscopy (RSRL)

Given 3 minutes before the induction agents and succinylcholine

Pre-treatment Drugs

•  Fentanyl    1mcg/kg over 30-60 sec
•  Lignocaine       1.0-1.5ml/kg

Apply ABC principle

A	Asthma, reactive airway disease	Use lignocaine
B	Brain, increased ICP	Use lignocaine or fentanyl
C	Cardiovascular, IHD, hypertension, ICB	Use fentanyl

Based on current evidence, the following previous practices are no longer recommended:

• use of defasciculating, non-depolarizing muscle relaxant in high ICP and penetrating eye injury
• use of atropine to prevent succinylcholine-induced bradycardia in small children.

4. Paralysis with induction

Administration of rapidly acting induction agent in a dose adequate to produce prompt unconsciousness immediately followed by neuromuscular blocking agent

Induction Agent	Dosing	Advantages	Disadvantages
Midazolam	0.1-0.5mg/kg	Amnetic, sedative	Hypotension, respiratory suppression
Ketamine	2mg/kg	Good bronchodilator, used in Asthma, severe hypotension/shock	Increased BP/HR/ muscle tone/ salivation/ IOP, readily cross placenta
Etomidate	0.3mg/kg	Very cardiostable, used in cardiac patient and haemodinamically unstable patient	Suppression of synthesis of cortisol
Propofol	2.0-2.5mg/kg	Conscious sedation	Depression of cardiovascular/ respiratory

Neuromuscular blocking agent:

1.Scolene (suxamethonium / succinylcholine) - depolarising muscle relaxant

•    Adult           1mg/kg
•    Children   2mg/kg
•    Neonate       3mg/kg

   Onset :  within 60sec

Duration : 3-5minutes

Adverse effects

- hyperkalaemia (increased by 0.5mmol/l)

- Bradycardia

- malignant hyperthermia

- increased ICP/IOP

 observe for fasciculation

2. Esmeron (recuronium) - non-depolarising muscle relaxant

• Dose            0.6-1.2mg/kg
• SE: hypokalaemia

Test for patient's jaw for flaccidity

• 45sec after administration of scolene
• 60sec after administration of rocuronium

5. Positioning

The head should be extended on the neck (Sniffing position). If cervical spine trauma is suspected, have an assistant provide in-line immobilisation.

Sellick maneuvre (application of firm pressure on cricoid cartillage to prevent passive regurgitation) is considered optional because it can worsen laryngoscopic view and impair tube insertion.

6. Placement with proof

During this stage, laryngoscopy is performed to visualize the glottis. The endotracheal tube is then passed in between the vocal cords, and a cuff is inflated around the tube to hold it in place and prevent aspiration of stomach contents.

Proof:

• Direct visualisation
• Calorimetric end tidal CO2 detector
• Vapour in ETT
• SPO2 monitoring
• 6 points auscultation
• Chest rise

7. Post-Intubation Management

1. Secure ET tube, note depth of initial tube placement on documentation
2. Initiate mechanical ventilation
3. RT insertion - confirmed by rapid introduction of air in 10cc syringe with auscultation at epigastic
4. CXR
5. Assess pulmonary status (remember CXR does not confirm placement, but assesses the tube height
6. above the carina). Ensure that mainstem intubation has not ocurred
7. Administer sedative/analgesia for patient comfort, decreased oxygen demand and to decrease ICP, 
8. Obtain arterial blood gases, if facility is capable
9. Document all components of the procedure accurately/ completely including time, tube size, depth of insertion and number of attempts
10. Maintain rigorous patient monitoring and oversight for continued ventilatory effectiveness
11. sedation and paralysis, hemodynamic stability and patient comfort

Example: IV midazolam infusion (20mg in 20cc NS run 2cc/H) and IV Fentanyl (200mcg in 20cc NS run 2cc/H)

13. May give IV Ranitidine 50mg to reduce the risk of gastric aspiration
14. Insert CBD

Complications

Esophageal intubation

Right mainstem intubation

Failure to intubate

Hypotension

Aspiration

Iatrogenic induction of obstructive airway

Pneumothorax

Dental/oral trauma

Post intubation pneumonia

Vocal cord avulsion