Adult Rapid Intubation
Protocol number: GEN-005
Description: Adult Rapid Sequence Intubation (RSI)
Date implemented: March 7, 2006
Last revision date: implementation
RSI, also known as Drug Facilitated Intubation, is a process of using drug induced unconsciousness and muscle paralysis to assist in providing a definitive airway by Endotracheal Intubation (ETI). Patients who are in cardiopulmonary arrest, impending cardiac arrest, unconscious from overdose or catastrophic neurological insult are usually flaccid and thus offer no muscular resistance to intubation attempts. However, there are patients with intact gag reflex and muscle rigidity who require airway control who do present an obvious management problem to the pre-hospital provider.
Advanced pre-hospital providers should already know how to manage airways and administer drugs, so there are no new skills to learn in RSI, in one sense. On the other hand, considering the fact that you are intentionally making the patient unconscious and apneic by your action makes the decision to perform RSI very important. A careful Risk-Benefit analysis must be performed. The decision must be made that this individual patient requires definitive airway management. There must be an expectation for complications and preparation for management of those complications. It is generally accepted that five percent of pre-hospital intubations will require RSI. Therefore, we must acknowledge that this is an infrequently used, high risk intervention, with potential for a great benefit to a small group of patients. In rural to remote access areas like Franklin County, the issues are different compared to an urban EMS system which has short transport times and ready access to a tertiary care facility. We believe there is a benefit to aggressive airway management when faced with long transport times and difficult access to specialty care centers and this weighs more against the very real risks of RSI. Implementation of a RSI protocol assumes adequate initial training, frequent revisits of the knowledge, skills, and decision making processes, and a vigorous continuous quality improvement process.
Providers are required to have successfully completed RSI specific training offered by the Franklin County Public Safety Operational Medical Director (OMD).
This protocol is designed to be a STANDING ORDER with recommendation of ONLINE CONSULTATION when available. Implementation of this protocol is scheduled to take place over two (2) phases. The purpose of the phased implementation is to allow for adequate accumulation of experience and data related to RSI and the airway management process. However, if the recommended personnel are not available and the trained provider feels that RSI would benefit the patient, the provider may perform RSI ONLY with ONLINE MEDICAL DIRECTION.
Phase 1 (evaluation period tentatively scheduled through July 2006 then institution of Phase 2)
Career Paramedics will receive RSI and airway management training and will begin standing order field RSI procedures provided that an ALS SUPERVISOR (Training 1, PS3, PS4, PS5, or EMS1) is on scene with the patient. Minimum or two (2) ALS providers with patient throughout transport.
Phase 2 (pending Phase 1 success, evaluation through December 2006 then any needed revisions)
Phase 1 plus:
Career Paramedics will receive Standing Order, with optional Online Consultation, without Supervisor on scene. Minimum or two (2) ALS providers with patient throughout transport.
Volunteer Paramedics will receive RSI and airway management training and will begin standing order field RSI procedures provided that an ALS SUPERVISOR (Training 1, PS3, PS4, PS5, or EMS1) is on scene with the patient. Minimum or two (2) ALS providers with patient throughout transport.
*At this time only RSI of adult patients (Age >12, Weight >40kg) is being considered due to a lack of adequate rescue airways for pediatric patients
· Patient in whom a cricothyrotomy would be difficult or impossible
· Patient who would be difficult to ventilate due to anatomy or obstruction
· Known pseudocholinesterase deficiency
· Known hyperkalemia (if using succinylcholine)
· Skeletal muscle myopathy (Muscular dystrophy, myasthenia gravis)
· Lack of required personnel present with patient
Ø Adult Intubation Kit including:
· Laryngoscope handle
· Assorted laryngoscope blades (min. #4 Macintosh and #3 or #4 Miller blades)
· Endotracheal tubes to include a size above and below the anticipated tube size
· 10 ml syringe
· Water based lubricant
· Endotracheal tube stylette
· Tube restraint device
· Esophageal intubation detector (preferably the syringe type)
· Bougie introducer
· End tidal CO2 detector
· Assorted oral and nasal pharyngeal airways
Ø Bag valve mask with supplemental oxygen
Ø Laryngeal mask airways or assorted sizes
Ø Combitube SA airway (for patients greater than 6’5” use the Combitube airway)
Ø Melker airway kit
Ø Capnography (optional but highly recommended)
Ø Telemetry including ECG and Pulse Oximeter
Ø RSI medications and needed administration devices (Etomidate, Succinylcholine, Vecuronium, Valium, Atropine, and Lidocaine)
If the patient is conscious, advise them of the EMERGENT NEED for this procedure and obtain informed consent.
IF UNSUCCESFUL AFTER THIRD ATTEMPT OR IT HAS BEEN LONGER THAN NINETY (90) SECONDS FOLLOWING ADMINISTRATION OF SUCCINYCHOLINE, INSTITUTE THE EMERGENCY AIRWAY PATH:
Ø Insert basic airway adjunct and ventilate with BVM and oxygen
Ø Insert Combitube SA (if successful, refer to SUCCESSFUL portion above)
Ø Insert properly sized LMA (if successful, refer to SUCCESSFUL portion above)
Ø Perform invasive airway technique as certified ( Melker airway kit, Quick-Trach, needle cricothyrotomy, surgical cricothyrotomy) (if successful, refer to SUCCESSFUL portion above)
AN ADEQUATE AIRWAY MUST BE OBTAINED!!!!!!