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Adult Rapid Intubation
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Protocol number: GEN-005
Description: Adult Rapid Sequence
Intubation (RSI)
Date implemented: March 7, 2006
Last revision date: implementation
OMD: N/A
Reviewed Date/By:
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INTRODUCTION:
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.
TRAINING:
Providers are required to have
successfully completed RSI specific training offered by the Franklin
County Public Safety Operational Medical Director (OMD).
IMPLEMENTATION:
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.
INDICATIONS:
*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
CONTRAINDICATIONS:
ABSOLUTE
·
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
RELATIVE
·
Known hyperkalemia (if using
succinylcholine)
·
Skeletal muscle myopathy (Muscular
dystrophy, myasthenia gravis)
·
Lack of required personnel present with
patient
EQUIPMENT:
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
Quick-Trach
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)
PROCEDURE:
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!!!!!!
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