The positioning of the patient is paramount, as is the correct use of the laryngoscope. Definition rapid sequence intubation rsi is the virtually simultaneous administration of a sedative and a neuromuscular blocking paralytic agent to render a patient rapidly unconscious and flaccid in order to facilitate emergent endotracheal intubation and to minimize the risk of aspiration. I liked the concept of rsa rapid sequence airway as opposed to rsi rapid sequence inductiongood for changing ems culture and mindset about airways. Consider naso or orogastric tube placement in all intubated patients to limit aspiration and decompress stomach if needed. Current practices and safety of medication use during rapid.
In emergency situations, a simple and standardised rsi protocol may improve the safety and effectiveness of the procedure. Rapid sequence induction and intubation rsii for anesthesia is a technique designed to minimize the chance of pulmonary aspiration in patients who are at higher than normal risk. Airway management is one of the most important skills for an emergency department practitioner to master because failure to secure an adequate airway can quickly lead to death or disability. In the emergency department rapid sequence intubation. This protocol is only for use in patients with an age 12 or greater or patients longer than the broselowluten tape. Pharmacology for intubationrapid sequence inductionpages summary. Rapidsequence intubation is the preferred method to secure airway in patients who are at risk for aspiration because it results in rapid unconsciousness induction and neuromuscular blockade paralysis. Current practices and safety of medication use during. The development of this course has been supported by an educational grant from nhs education scotland.
Rapid sequence intubation pharmacology page 2 of 6 acep. Bp effect minimal no analgesia myoclonus possible nausea vomiting propofol 1 mgkg iv 70kg 40 60mg per. Rsi the use of medication to facilitate passing the endotracheal tube analgesics sedatives paralytics controlled procedure will take several minutes to accomplish requires a team effort the ultimate goal is to secure an airway without having the patient vomit and aspirate. Application of cricoid pressure cp for patients undergoing rapid sequence intubation is controversial. With the 2010 changes by the aha, this skill was no longer recommended as a routine. In summary, there are two classes of drugs used for performing a rapid sequence induction and intubation. Drugs to aid intubation merck manuals professional edition. Currently, the rapid sequence induction and intubation is the technique of choice for securing the airway in patients at risk of aspiration 12 3. Rapid sequence intubation emergency medicine journal. Emergency physicians have established expertise in the field of rapid sequence intubation rsi. Feb 10, 2017 a presentation that discusses a pharmacists role and the medications used in rapid sequence intubation.
Airway, rapid sequence intubation optional protocol 3. We thank the authors for their commitment to training this essential skill. Rapid sequence induction of anaesthesia rsi is the recommended method to facilitate emergency tracheal intubation in trauma patients. Jess mason md, mel herbert md, scott weingart md and drew merriman md. If there is residual muscle tone and clear signs of life but the patient is in extremis consideration should be given to intubation using paralysis only. The abreviated cold intubation checklist should be used in these cases.
Longer acting paralytics may be needed postintubation. Davis dp, dunford jv, poste jc, ochs m, holbrook t, fortlage d, et al. In advanced airway management, rapid sequence induction rsi also referred to as rapid sequence intubation or as rapid sequence induction and intubation rsii is a special process for endotracheal intubation that is used where the patient is at a high risk of pulmonary aspiration or impending airway compromise. In the prehospital and emergency setting, however, a simple and standardised rsi protocol may. Administration of either the neuromuscular blocking or the sedative agent first are both acceptable. Relevant articles published from 1968 to 2006 were selected from the medline, lilacs and scielo databases, using the keywords intubation, tracheal intubation, child, rapid sequence intubation and pediatric airway. Rapid sequence intubation rsi is defined as an airway management technique in which a potent sedative or anesthetic induction agent is administered simultaneously with a paralyzing dose of a neuromuscular blocking agent to facilitate rapid tracheal intubation. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury davis, d. Endotracheal intubation using rapid sequence intubation rsi is the cornerstone of emergency airway management. Pharmacology for intubation rapid sequence inductionpages summary.
His gcs is 6 and he is making gurgling sounds when he breathes. Once a patient has been given a paralytic drug, you are responsible for ventilations if desaturation occurs. Blockade adjuncts pretreat special concerns head trauma pentothal 35mgkg succinylcholine 1. Any local ems system changes to this document must follow the nc oems protocol change policy and be approved by oems. Current practices and safety of medication use during rapid sequence intubation article in journal of critical care 45.
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. All emergency physicians must be facile not only with the skill of intubation, but also with the different pharmacologic agents appropriate for unique airway scenarios. Rapid sequence induction drugs critical care practitioner. During intubation, if visualizing the vocal cords is difficult, there are some skills that can help. Posted in airway, blog, rapid sequence intubation, resuscitation. To avoid such spread, certain practices used in standard rapid sequence intubation rsi must be modified. Elaboration of the procedure of delayed sequence intubation. Anesthesia 46199, picu 45488, clinical pharmacy 43765 clinical scenario pre.
These steps also allow for any patient requiring advanced airway protection to be intubated with a decreased risk of. Commonly given in 2040mg boluses and titrated to effect. Rapid offset short half life, often used in procedural sedation. Speedbomb a simple and rapid checklist for prehospital.
Rapid sequence intubation is a cornerstone of emergency medicine, and in the pediatric emergency medicine world, the frequency with which we intubate our patients is less compared to our adult em counterparts. Pharmacology for intubationrapid sequence inductionpages. He has a tense, rigid abdomen, bilateral femoral fractures and an unstable pelvis. The impact of rapid sequence intubation on trauma patient mortality in attempted prehospital intubation. Acep now offers realtime clinical news, news from the american college of emergency physicians, and news on practice trends and health care reform for the emergency medicine physician. Rapid sequence intubation pharmacology page 2 of 6. G e n e r a l p r o t o c o l s pearls agencies must maintain a separate performance improvement program specific to rapid sequence intubation. This module will detail the most common drugs used for rapid sequence induction and intubation. Sep 01, 2010 acep now offers realtime clinical news, news from the american college of emergency physicians, and news on practice trends and health care reform for the emergency medicine physician. Current practice of rapid sequence induction of anaesthesia. Rapid sequence intubation and the role of the emergency department pharmacist jeremy p. Acep now is an official publication of the american college of emergency physicians. 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. Application of cricoid pressure cp for patients undergoing rapidsequence intubation is controversial.
Take home points patients with an anticipated difficult airway but sufficient respiratory reserve to allow preparation may be candidates to perform awake intubation. Infant neuromuscular blocking agent before the sedative agent was associated with a reduction in time from rsi administration to the end of intubation attempt of 6 seconds 95% confidence interval 0 to 11 sec. The aim is to intubate the trachea as quickly and as safely as possible. Rapid sequence intubation is a stepwise process developed to assist health care providers in placing emergent artificial airways for patients requiring assisted ventilation. Rapid sequence induction bja education oxford academic. Speedbomb a simple and rapid checklist for prehospital rapid sequence induction abstract prehospital emergency medical services often operate in the most challenging and austere environments. The technique includes specific protection against aspiration of. Definition rapid sequence intubation rsi is the virtually simultaneous administration of a sedative and a neuromuscular blocking paralytic agent to render a patient rapidly unconscious and flaccid in order to facilitate emergent endotracheal intubation and to.
Rapidsequence intubation and the role of the emergency. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely headinjured patients. Rapidsequence intubation and the role of the emergency department pharmacist jeremy p. Jan 23, 2016 definition rapid sequence intubation rsi is the virtually simultaneous administration of a sedative and a neuromuscular blocking paralytic agent to render a patient rapidly unconscious and flaccid in order to facilitate emergent endotracheal intubation and to minimize the risk of aspiration. Editor,all emergency medicine specialists should be competent in rapid sequence intubation rsi. Rapid sequence intubation is the preferred method to secure airway in patients who are at risk for aspiration because it results in rapid unconsciousness induction and neuromuscular blockade paralysis. Rapid sequence intubation and rapid sequence airway. Significant modification of traditional rapid sequence. Checklist use for complex tasks in these circumstances is useful, but must make task completion simpler, faster and more effective. Protect the patient from self extubation when the drugs wear off. The classical technique of rapidsequence induction of anaesthesia was introduced in 1970s, and there may be a wide variation of techniques now, as a result of introduction of new drugs, equipment, and concepts.
Use 4% lidocaine and an atomizer device to anesthetize the airway. It is a complex intervention with significant risks and the procedure is often tailored to the individual patients requirements 2,3. Furthermore, the pediatric patient is considered a difficult airway by virtue of being a child, and their physiology gives them less reserve at. Apr 07, 2020 the impact of rapid sequence intubation on trauma patient mortality in attempted prehospital intubation. Intro to drugs used in rapid sequence intubation pemblog. The usual, nonrapid sequence of induction and intubation for anesthesia consists of administration of an induction agent, proof of the ability to mask ventilate. A presentation that discusses a pharmacists role and the medications used in rapid sequence intubation. In this video you can see a demonstration of rapid sequence intubation, as well as the correct use of the introducer and bougie. A crucial component of developing a standardised protocol is the selection of induction agents. Rapid sequence intubation sharonelizabethmace,md, facep, faap a,b c d definitionoverview rapid sequence intubation rsi is a process whereby pharmacologic agents, specifically a sedative eg, induction agent and a neuromuscular blocking agent are admin.
Rapid sequence intubation clinical medicine medical. Rapid sequence induction rsi is an established method of inducing anaesthesia in patients who are at risk of aspiration of gastric contents into the lungs. A postal survey was made to examine the variation of this technique in the uk. Rapid sequence intubation rsi overview rapid sequence intubation rsi is an airway management technique that produces inducing immediate unresponsiveness induction agent and muscular relaxation neuromuscular blocking agent and is the fastest and most effective means of controlling the emergency airway. Propofol mgkg is commonly used in the operating theatre for patients who are haemodynamically stable. Rapid sequence intubation technique medscape reference. Dec 16, 2006 the effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury davis, d.
Techniques for improving patient care and minimizing infectious risks to care providers and spread of the virus during emergency intubation are summarized in the following table table 1 and discussed in greater detail separately. It differs from other forms of general anesthesia induction in. Skeletal muscle relaxation with an iv neuromuscular blocker markedly facilitates intubation. This practice includes routine administration of sedative and neuromuscular blocking agent nmba medications for patient comfort during endotracheal tube placement. Atotw 331 th rapid sequence induction 24 may 2016 page 4 of 8 preparation of equipment preparation of drugs hypnotics five drugs are commonly used to induce anaesthesia. One of the main side effects of propofol is hypotension. Rapid sequence induction and intubation request pdf. With the 2010 changes by the aha, this skill was no longer recommended as a routine use of helping als providers visualize the vocal cords.