Rapid Sequence InductionRFFE ALS Waiver Training

Rapid Sequence Induction

The combined use of a sedative and paralytic to place an endotracheal tube.

Contraindications

• Patient is 12 years of age or younger• Able to manage patient in excited delirium with Ketamine alone• Able to manage patient who is combative using Haldol alone• Able to intubate without sedation and/or a paralytic• Difficult airway with risk of failed intubation if alternative is viable

Indications

• Respiratory insufficiency• Inability to maintain airway• Impending loss of airway• GCS ≤ 8• Increased security of an ETT desired

Preparation

1. Pre-oxygenate with 100% oxygen up to 5 minutesAvoid BVM if possible to prevent gastric distention

2. Apply cardiac, ETCO2 and SpO2 monitors3. Establish IV/IO access4. Place patient in ramped, extended position if possible

Airway Alignment

Airway Alignment

Airway Alignment

Airway Alignment

Airway Alignment

Equipment

Make available:1. Suction2. ETT – at least 2 sizes3. Bougie4. Tape5. Cricothyroidotomy Set6. OG/NG Tube

Medications

Draw medications:Ketamine 2mg/kg: Use 6ml syringe

dose range should approximate 100mg to 250mgsupplied 50mg/ml = 2ml to 5ml

Rocuronium 1mg/kg: use 12ml syringedose range should approximate 50mg to 125mgsupplied 10mg/ml = 5ml to 12.5ml

Procedure

1. Verify dose and administer Ketamine IV/IO

2. Verify dose and administer Rocuronium IV/IO

3. Bump under head or ramp for ideal visualization

4. Use cricoid pressure and/or manipulation if desired

5. Secure tube and record tube position

6. Verify oxygen

7. Use transport ventilator if available

8. Continue Cardiac, ETCO2 and SpO2 monitors

9. Place OG/NG Tube

Procedure

Procedure

Procedure

Failed Intubation

1. Unsuccessful after 3 attempts

2. Oxygenate with BVM for up to 5 minutes if possible

3. Attempt Supraglottic Airway

4. Place NP Airway

5. Continue to BVM if possible

6. Consider Cricothyroidotomy if above unsuccessful or inadequate

Ketamine Pharmacology2mg/kg

Commercially available in 1970

Derived from PCP

Dissociative Anesthetic (catatonia, catalepsy, amnesia)

Analgesic (on-par with opioids)

Anti-inflammatory (by suppression of pro-inflammatory cytokines)

Anti-depressant

Onset of Action 10-30 seconds

Duration of Action 5-15 minutes

Rocuronium Pharmacology

Introduced 1994

Non-depolarizing neuromuscular blocker

Onset of action 1 minute (30 sec to 6 minutes)

Duration of action 30-45 minutes (15-85)

Colorado RSI Waiver Details

2018 12017 42016 22015 1

Granted given consideration of prolonged transport times.