Rapid Intubation

Erica CorraoOct. 19, 2012Health Education for Allied HealthYoungstown State University

What is Rapid Intubation

The cornerstone for emergency airway management

Results in rapid unconsciousness and paralysis in a patient

Considered a crash airway

Indications

Inability to maintain airway patency

Inability to protect the airway against aspiration

Ventilatory compromise

Failure to adequately oxygenate pulmonary capillary blood

Anticipation of a deteriorating course that will eventually lead to the inability to maintain airway patency or protection

Goal

To intubate the trachea without having to use bag-valve-mask ventilation

Without using sedative agents alone

Administration of weight-based doses of an induction agent immediately followed by a paralytic agent to get the patient unconscious within 1 minute

Contraindications

Absolute- total upper airway obstruction & total loss of facial/oropharyngeal landmarks

Relative- anticipated difficult airway to achieve

Crash airway- when the patient is in an arrest situation, unconscious and apneic

Anesthesia

3 phases of medication administration

Pretreatment, induction, and paralysis

Preoxygenation

Preoxygenation with nonrebreather mask for 5 minutes prior

Allows the patient to maintain blood oxygen saturations during the apneic period of paralysis and allow for more time to intubate

Pretreatment

Used to help the response to larygnoscopy and induction and paralysis

Typically administered 2-3 minutes prior to induction and paralysis

Examples are LOAD (lidocaine, opioid analgesic, atropine, defasciculating agents

Induction

Provide rapid loss of consciousness that helps ease the intubation and avoids psychic harm to the patient

Examples of meds are: Etomidate, Ketamine, Propofol & Midazolam

Paralysis

Need to be administered immediately after the induction agent

Neuromuscular blockade does not provide sedation so administering a right dose of the induction agent is important

Equipment Needed

Laryngoscope

Endotracheal tube

Stylet

10 mL syringe

Suction Catheter

CO2 detector

Oral and Nasal airway

Ambu bag and mask

Positioning

Place patient in sniffing position for adequate visualization. You will need to flex the neck and extend the head

This position helps with visualization of the glottic opening

Technique

PreparationConfirm that equipment is functional

Assess for difficult airway

Establish Intravenous access

Draw up drug and determine sequence

Review contraindications to meds

Attach monitoring equipment

Check endotracheal tube for leak

Ensure function light bulb on laryngoscope blade

Technique

PreoxygenationAdminister 100% oxygen through nonrebreather mask for 5 minutes for nitrogen washout

Assist ventilation with bag-valve-mask system only if needed to keep oxygen saturations greater than or equal to 90%

Technique

PretreatmentSee Anesthesia slide for more information

Consider administration of drugs to mitigate the adverse effects of intubation

Technique

Induction of ParalysisGive a rapid acting induction medication to produce loss of consciousness

Administer neuromuscular blocking agent immediately after the induction agent

Should be given by intravenous push

Technique

Protection and PositioningProvide cricoid cartilage pressure

Maintain pressure until ETT is verified in position

Technique

Placement with ProofVisualize the ET tube passing through vocal cords

Confirm tube placement with a color change by CO2 dector and auscultation

Technique

Postintubation ManagementSecure ET tube in place

Initiate mechanical ventilator

Obtain chest x-ray

Administer proper meds for patient comfort and other factors

Complications

Esophageal intubation

Iatrogenic induction of an obstructive airway

Right mainstem intubation

Pneumothorax

Dental trauma

Postintubation pneumonia

Complications

Vocal cord avulsion

Failure to intubate

Hypotension

Aspiration

Conclusion

Rapid Sequence Intubation (RSI) is the preferred technique in emergency departments.

It is not indicated in a patient who is unconscious and apneic.

Approach with caution in a difficult airway

Proper technique is key

Reference

Rapid Sequence IntubationMedscape Reference

medicine.medscape.com/article/80222-overview