1. CAP – Module 3 Endotracheal Intubation - Rapid Sequence Intubation
GHEMS_V

2. Objectives Review Anatomy and Physiology
Understand the concept of Comprehensive Airway Management
Review the concepts of RSI
Review the approach to the difficult airway
Know the protocols associated with airway management

4. Airway Management Airway management involves multiple skills Knowledge
Judgment
Dexterity
All of these improve with field experience

5. Airway Management Decision to Intubate
Is there a failure to maintain or protect the airway?
Is there a failure of ventilation or oxygenation?
What is the anticipated clinical course?

6. Airway Management Decision to Intubate
Is there a failure to maintain or protect the airway?
Gag reflex vs. Swallowing
Immediately reversible conditions
Opiod overdose
Cardiac dysrhythmias
Note that the gag reflex can be imprecise; volitional swallowing means the patient can protect the airway

7. Airway Management Decision to Intubate
Is there a failure of ventilation or oxygenation?
Asthma: oxygenates adequately, ventilatory failure
Pulmonary Edema: ventilates adequately, oxygenates poorly

8. Airway Management Decision to Intubate
What is the anticipated clinical course?
Multiple system trauma patient
Tricyclic antidepressant overdose
Neck injuries

9. Endotracheal intubation
Indications
Respiratory or cardiac arrest
Obtundation or unconsciousness without gag reflex
Risk of aspiration
Airway obstruction
Respiratory extremis secondary to disease or trauma
Optional slide

10. Endotracheal intubation
Contraindications
Epiglottitis, unless airway obstruction imminent
Inability to identify airway landmarks
Optional slide

11. Endotracheal intubation
Advantages
Isolates the trachea
Prevents gastric distention
Eliminates need for mask seal
Provides direct route for respiratory suctioning
Optional slide

12. Endotracheal intubation
Disadvantages
Requires training and experience
Requires specialized equipment
Requires direct visualization of vocal cords
Bypasses upper airway’s functions of warming, filtering, humidifying inhaled air
Optional slide

13. A&P Review Upper airway Nasopharynx Oropharynx Laryngopharynx Larynx
OBJ: anatomy review: depth should be tailored to needs of least experienced operator

14. A&P Review Glottic structures Glottic opening Vocal cords
Cuneiform cartilage
Corniculate cartilage
Together make up the
Arytenoid Cartilage

15. A&P Review Laryngeal landmarks Thyroid cartilage Cricothyroid membrane
Cricoid membrane
Thyroid gland
OBJ: important to correlate laryngeal anatomy with surface anatomy landmarks

16. Cricoid Pressure Also called Sellick’s maneuver
Posterior displacement of cricoid ring occludes esophagus.
Helps prevent
Gastric insufflation
Passive regurgitation of vomitus in supine, obtunded, or paralyzed patients
OBJ: Sellick’s maneuver needs to be emphasized, as part of the CAM team approach; operator needs to know that it is being performed adequately

17. Cricoid Pressure Technique
Hold cricoid cartilage between thumb and index finger.
Apply posterior pressure.

18. Cricoid Pressure
Before and After

19. Cricoid Pressure vs. Laryngeal Manipulation
CP may move the glottic opening posteriorly, enhancing visualization of the cords.
If goal is to move glottis into view, utilize laryngeal manipulation, not CP.
BURP maneuver (backward, upward, and rightward pressure on larynx)
Much more effective than CP at relocating glottis to position of increased visibility
OBJ: differentiate Sellick’s maneuver and Laryngeal manipulation; emphasize importance of former

20. Rapid Sequence Intubation (RSI)
The administration of a potent sedative (induction) agent followed immediately by a rapidly acting neuromuscular blocking agent (NMBA) in order to induce unconsciousness and motor paralysis to facilitate endotracheal intubation (ETI)
OBJ: major point is paralytics, while improving first attempt success rate, eliminate any respiratory drive and airway protection (adequate or inadequate), thus placing an extra onus of expertise on the airway operator

21. RSI
RSI assumes the need for immediate airway control and a full stomach with risk of aspiration
Maximizes your chances
Increases the risk

22. RSI Rapid Sequence Intubation Preparation Preoxygenation Pretreatment
Paralysis with induction
Protection and positioning
Placement with proof
Postintubation management
This is the Emergency Medicine format for the steps of RSI, not always taught in all paramedic programs

23. RSI: Preparation
Assess airway. Have plan ready for failed airway. Make sure all present are familiar with it.
Induction agent and paralytic drawn
Labeled syringes
Contraindications to drugs reviewed
Preoxygenation of patient
Monitor Heart rate and SaO2
OBJ: operator makes airway assessment and formulates a plan/algorithm
OBJ: team members assigned to oxygenation/ventilation will begin preoxygenation during this step
OBJ: team member needs to be assigned to monitor HR (for bradycardia) and SaO2 (for desaturation past the 90% point, if the patient is above that)
Note: one person can be assigned to oxygenate/ventilate and monitoring, possibly Cricoid Pressure too, but beware overtasking. Know the team members’ abilities.

24. RSI: Preoxygenation
Creates oxygen reservoir within blood and body tissues
Allows for several minutes of apnea without arterial oxygen desaturation
Patient should be administered 100% oxygen for five minutes before administration of NMBA.
OBJ: team member assigned to this task should be directed: 1. what preoxygenation method (NRB, BVM with some/full ventilatory assist) and 2. be ready with BVM for post intubation management

25. Apnea and Hypoxia
OBJ: The point here is the rapid dropoff of SaO2 below 90%. This is the point where the lungs’ oxygen reservoir is used up, and hypoxic brain damage begins. While a normal, healthy adult has about 8 minutes to 90%, the moderately (note: not critically) ill patient has about 5, and the obese adult (note: only 250 lbs) has about 2.5 minutes. Thus the pressure for skilled and quick laryngoscopy, not just successful ET placement, particularly when the operator paralyzes the patient.

26. RSI: Pretreatment Pretreatment medications are administered IV.
Lidocaine
(for reactive airways or increased ICP)
Atropine
( For Children <8 years old)
OBJ: This is meant to stimulate the discussion of what drugs should be given to premedicate.. We no longer advocate the use of lidocaine in the ICP patient. The induction agent Etomidate has some properties of decreasing ICP. Atropine should be administered to any pediatric patient (less than 12 years of age). Fentanyl or other narcotics can be given as POST INTUBATION MANAGEMENT, but generally complicate RSI.

27. RSI: Paralysis with Induction
Pre-Medication:
Propofol
Versed
Paralysis:
Succinylcholine
medications administered rapid IV push
Loss of consciousness and paralysis will occur rapidly
OBJ: Etomidate should be standard induction agent; discuss use of midazolam (not currently prohibited by protocol), its indicated doses (e.g mg—not ‘conscious sedation doses’)
OBJ: note contraindications of succinylcholine: possible hyperkalemic states
Note: Etomidate administered in half dose in cases of hemodynamic instability. Etomidate is relatively safe, but if we are going to see hemodynamic compromise from this drug we would see it in the sickest, “shocky” patients.

28. RSI: Protection and Positioning
Cricoid pressure should be applied the moment loss of consciousness is noted.
Maintained until ETT placement confirmed
OBJ: note timing of Cricoid Pressure. Emphasize this is to be an assigned task given to a team member (EMT level skill). If Laryngeal Manipulation is needed, it might be done with the operator’s hand on the EMT’s hand (discussion point)

29. RSI: Placement with Proof
Patient's jaw should be adequately flaccid within 45–60 seconds
Administration of NMBA allows for optimal laryngoscopy.
ETI performed
Confirm with ETCO2, auscultation.
OBJ: county protocol mandates confirmation and documentation of successful placement by three routes, one of which must be EtCO2 (waveform [“good” is ok] and number)

30. RSI: Placement with Proof
Do not rush intubation!
Monitor SaO2 .
Laryngoscopy can be performed as long as SaO2 remains above 90%.
May be minutes if patient is properly preoxygenated
Stop laryngoscopy and provide BVM ventilations with cricoid pressure until SaO2 is back to prelaryngoscopy level.
Note: This is where it is important to emphasize a team approach, not only to assist with equipment and Sellick’s maneuver, but also have someone monitor the patient’s heatrate and SaO2.
OBJ: Snohomish County defines intubation attempts as an ET passing the gums. This does NOT, however, endorse multiple laryngoscopies without ET placement attempt, with BVM ventilations in between to keep SaO2 above 90%. Make note that this is not a best practice. If a laryngoscopy is not successful, the operator should move on to plan B in their algorithm.

31. RSI: Post-Intubation Management
Tube secured
Initiate ventilation
Cervical collar applied
Patient immobilized to backboard
Post-intubation medications
Propofol
Versed
Valium
Vecuronium/Pancuronium prn
OBJ: stress postintubation management, avoid patients who are intubated and paralyzed but not adequately sedated
OBJ: Protecting a successfully placed ET is of paramount importance in the relatively chaotic prehospital venue, thus further NMBA doses are allowed, but optimal management is with sedation +/- analgesics alone. Note why this is so (serial neurologic evaluation, detection of seizure activity). The onus is on the operator to make an informed, defensible decision.
If Valium or Versed is used also use Fentanyl 50 mcg

32. Pre-Medication

33. Pre-Medication

34. NOTE: DOSE SHOULD BE REDUCED BY 50% IN THE ELDERLY
Pre-Medication
NOTE: DOSE SHOULD BE REDUCED BY 50% IN THE ELDERLY

35. Paralysis

36. Paralysis

37. Paralysis