In the past, when EMS arrived, the patient’s condition could range from morbidity to simply “running out of steam.”  If the patient was combative or awake, the paramedic was forced to delay rather than attempt an intubation with the few tools available in the field.  This delay was often to the patient’s detriment.  It is clear that many of these patients would benefit from early intubation. Until recently paramedics were quite limited in the tools available to control movement and sedate the patient.  This has completely changed with a technique known as Rapid Sequence Intubation (RSI).  RSI is defined as the rapid administration of both a neuro-muscular blocking agent and a potent sedative agent to facilitate intubation while decreasing the risks of aspiration, combativeness and potential damage to the patient.

There are few more important tasks in emergency medicine than airway management.  Whatever method is used must be effective, for the problem does not allow the luxury of waiting until the “physician” arrives, or until the problem has cured itself.  There is ample evidence that both pediatric and adult patients emergently intubated with the principles of RSI have both lower complication rates and higher success rates thank all other techniques.

Oxygen

Bag-Valve Mask with reservoir

Oral and Nasal Airways

Appropriately sized endotracheal tubes in various sizes

Laryngoscope with both curved and straight blades

Suction unit with catheters

Stylette

Water soluble lubricate

Medications pre-drawn for procedure

Tape

Pulse Oximeter

Quick Trach equipment

Airway compromise where other methods of airway control cannot be achieved.  Such as but not limited to, overdoses, seizures, facial burns and combative trauma patients.

1)      Spontaneous breathing with adequate ventilation and oxygenation

2)      Operator concern that both intubation and mask ventilation may not be successful due to:  major laryngeal trauma, upper airway obstruction, or airway anatomy

3)      Operator unfamiliarity with the medications used

1)      Prepare Equipment

2)      Hyperoxygenate the patient for 3 – 5 minutes.  Place the spontaneously breathing patient on high-flow oxygen by nonrebreather mask.  Do not attempt to assist the patient’s breathing if ventilation is adequate.  If, however, the patient does not have an adequate ventilatory effort, assist ventilations using a bag-valve- mask with 100% oxygen.

3)      Closely monitor the patient throughout the procedure.  Continuous monitoring of the patient’s level of consciousness, cardiac rhythm, and pulse oximetry is required.

4)      Medicate the patient as follows:

                                                               i.      Etomidate (Amidate)----------0.15 to 0.3 mg/kg intravenously (See Appendix A)

                                                             ii.      Vecuronium (Norcuron)-------).1 mg/kg intravenously (See Appendix B)

5)      As the patient becomes sedated, cricoid pressure should be applied

6)      Perform the intubation

7)      Verify tube placement

8)      Secure the tube

 

If the paramedic can’t GUARANTEE an airway, it WILL be FATAL to the patient

 

Etomidate (Amidate), is an ultrashort-acting, nonbarbiturate hypnotic agent that has been used as an induction agent for anesthesia for years.

 

Etomidate has minimal hemodynamic effects and may be the drug of choice in a hypotensive or trauma patient.  It causes less cardiovascular depression than either barbiturates or propofol.  Etomidate has been shown to decrease intracranial pressure, cerebral blood flow and cerebral oxygen metabolism.  For these reasons, Etomidate is the sedative of choice for pre-hospital RSI.

 

1)      Non-Narcotic, non-barbiturate sedative/hypnotic

2)      Sedation prior to paralyzing a patient for endotracheal intubation

1)      Pain at injection site

2)      Jerking of muscles

3)      Nausea and vomiting

4)      Tachycardia

5)      Apnea

1)     0.15 to 0.3 mg/kg IV

 

 

Vecuronium (Norcuron), is an amino-steroid non-depolarizing agent.  It has an intermediate duration of action of 30 – 60 minutes with an initial dose of 0.1 mg/kg.  It can produce clinical effects in 30 seconds and intubation paralysis in 1 – 4 minutes.  A priming dose of 0.01 mg/kg given 2 minutes before intubation will shorten the onset of vecuronium to about 30 seconds.

 

1)     Intermediate acting non-depolarizing agent

 

1)     Combines with acetylcholine receptors on muscle cells causing an inability to generate muscle contraction.

 

1)     Paralytic used for prolonged paralysis.

 

1)     Hypersensitivity to the drug.

 

1)     Prolonged paralysis

2)     Hypotension

3)     Bradycardia