Rapid Sequence Intubation: Mask and Monitoring

Rapid Sequence Intubation
Definition
Administration of potent induction agent after pre-oxygenation followed immediately by
rapidly acting neuromuscular blocking agent to induce unconscious and motor paralysis for
tracheal intubation without interposed positive airway ventilation
Indications for intubation

Inability to maintain patent
Upper airway sweling, facial/neck trauma, Poor GCS
airway/tone
Ventilatory compromise Hypoventilation, large pneumothorax, flail chest, Severe

COPD, status asthmaticus
Failure to adequately
Severe hypoxemia, APO, PE, ARDS
oxygenate
Anticipation of deteriorating
Severe haemorrhagic shock, ICB with poor GCS, Septic
course
shock
Contraindications
•Total upper airway onstruction
•Total loss of oropharyngeal/ facial landmarks
7 P's
1. Preparation
2. Pre-oxygenation
3. Pre-treatment
4. Paralysis with induction
5. Positioning
6. Placement with proof
7. Post-intubation management
1. Preparation
Patient must be managed in resuscitation area
Prepare yourself, have a skilled assistants
Prepare the equipment- Remember this mnemonic MALES+4S
Mask and •Non-rebreather mask/Bag valve mask

Monitoring •Cardiac monitor, pulse ox, BP cuff opposite arm with IV line
•Airway adjuncts (e.g. OPA, NPA, LMA) and Ask for difficult airway
Airway
trolley
•Blade – Mac 3 or 4 for adults – curved blade

Laryngoscope •Miller 3 or 4 for adults – straight blade
•Handle – attach blade and make sure light source works
•7.5 ET tube with stylet fits most adults, 7.0 for smaller females, 8.0 for
ETT
larger males
Suction •Immediate suction with a large bore Yankauer suction
Stylet placed inside ET tube for rigidity, bend it 30 degrees starting at proximal
end of cuff (i.e. straight to cuff, then 30 degree bend)
Stethoscope
Use this to listen to air entry and in ryles tube insertion later
Syringe and
Use syringe to inflate the cuff after successful intubation and tape to
securing tape
anchor the tube
Other suggested mnemonic: MARBLESx2 or SOAP-ME
Assess airway upon patient arrival. Use mnemonic LEMONS

•Look externally- for maxilofacial/neck trauma, beard, obesity, cachexia, edentulous mouth
•Evaluate 3:2:2 rule (3 fingers for mouth opening, 3 fingers between hyoid bone and mentum, 2
fingers between thyroid cartilage and hyoid bone
•Mallampati score- direct peroral pharyngeal visualization and that seen with laryngoscopy.
•Obstruction. Evaluation for stridor, foreign bodies, and other forms of sub- and supraglottic
obstruction should be performed in every patient prior to laryngoscopy.
•Neck mobility
2. Preoxygenation
Principle
•establishment of oxygen reservoir within the lung, blood and body tissue to permit several
minutes of apnoea without arterial oxygen desaturation
•no bagging principle
•Replacement of predominantly nitrogenous mixture of room air with oxygen allowing several
minutes apnea time before Hb saturation <90%
Principle reservoir - functional residual capacity (FRC) ~ 30ml/kg

Method
•Administration of 100% oxygen for 3 minutes,
•or by having the patient take 8 vital capacity breath while on 100% oxygen
3. Pretreatment
Administration of drugs to mitigate adverse effects associated with the intubation or patient's
underlying comorbidities.
Adverse effects include
• Bronchospastic reactive airway
• Increased ICP
• Reflex sympathetic response to laryngoscopy (RSRL)
Given 3 minutes before the induction agents and succinylcholine
Pre-treatment Drugs
• Fentanyl 1mcg/kg over 30-60 sec
• Lignocaine 1.0-1.5ml/kg
Apply ABC principle

A Asthma, reactive airway disease Use lignocaine
B Brain, increased ICP Use lignocaine or fentanyl
Cardiovascular, IHD, hypertension,

C Use fentanyl
ICB
Based on current evidence, the following previous practices are no longer recommended:
•use of defasciculating, non-depolarizing muscle relaxant in high ICP and penetrating eye injury
•use of atropine to prevent succinylcholine-induced bradycardia in small children.
4. Paralysis with induction

Administration of rapidly acting induction agent in a dose adequate to produce prompt
unconsciousness immediately followed by neuromuscular blocking agent
Induction Disadvantag
Dosing Advantages
Agent es
Hypotension,
Midazolam 0.1-0.5mg/kg Amnetic, sedative respiratory
suppression
Ketamine 2mg/kg Good bronchodilator, used Increased

BP/HR/
muscle tone/
in Asthma, severe
salivation/
hypotension/shock
IOP, readily
cross placenta
Very cardiostable, used in

Suppression
cardiac patient and
Etomidate 0.3mg/kg of synthesis
haemodinamically unstable
of cortisol
patient
Depression of
Propofol 2.0-2.5mg/kg Conscious sedation cardiovascula
r/ respiratory
Neuromuscular blocking agent:

1.Scolene (suxamethonium / succinylcholine) - depolarising muscle relaxant
• Adult 1mg/kg
• Children 2mg/kg
• Neonate 3mg/kg
Onset : within 60sec
Duration : 3-5minutes
Adverse effects
- hyperkalaemia (increased by 0.5mmol/l)
- Bradycardia
- malignant hyperthermia
- increased ICP/IOP
observe for fasciculation
2. Esmeron (recuronium) - non-depolarising muscle relaxant
•Dose 0.6-1.2mg/kg
•SE: hypokalaemia
Test for patient's jaw for flaccidity

•45sec after administration of scolene
•60sec after administration of rocuronium
5. Positioning
The head should be extended on the neck (Sniffing position). If cervical spine trauma is
suspected, have an assistant provide in-line immobilisation.
Sellick maneuvre (application of firm pressure on cricoid cartillage to prevent passive
regurgitation) is considered optional because it can worsen laryngoscopic view and impair tube
insertion.
6. Placement with proof

During this stage, laryngoscopy is performed to visualize the glottis. The endotracheal tube is
then passed in between the vocal cords, and a cuff is inflated around the tube to hold it in place
and prevent aspiration of stomach contents.
Proof:
•Direct visualisation
•Calorimetric end tidal CO2 detector
•Vapour in ETT
•SPO2 monitoring
•6 points auscultation
•Chest rise
7. Post-Intubation Management
1.Secure ET tube, note depth of initial tube placement on documentation
2.Initiate mechanical ventilation
3.RT insertion - confirmed by rapid introduction of air in 10cc syringe with auscultation
at epigastic
4.CXR
5.Assess pulmonary status (remember CXR does not confirm placement, but assesses
the tube height
6.above the carina). Ensure that mainstem intubation has not ocurred
7.Administer sedative/analgesia for patient comfort, decreased oxygen demand and to
decrease ICP,
8.Obtain arterial blood gases, if facility is capable
9.Document all components of the procedure accurately/ completely including time,
tube size, depth of insertion and number of attempts
10.Maintain rigorous patient monitoring and oversight for continued ventilatory
effectiveness
11.sedation and paralysis, hemodynamic stability and patient comfort
Example: IV midazolam infusion (20mg in 20cc NS run 2cc/H) and IV Fentanyl (200mcg in
20cc NS run 2cc/H)
13.May give IV Ranitidine 50mg to reduce the risk of gastric aspiration
14.Insert CBD
Complications
Esophageal intubation
Right mainstem intubation
Failure to intubate
Hypotension
Aspiration
Iatrogenic induction of obstructive airway
Pneumothorax
Dental/oral trauma
Post intubation pneumonia
Vocal cord avulsion

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Rapid Sequence Intubation

Indications for intubation

Ventilatory compromise Hypoventilation, large pneumothorax, flail chest, Severe

Mask and •Non-rebreather mask/Bag valve mask

•Blade – Mac 3 or 4 for adults – curved blade

Suction •Immediate suction with a large bore Yankauer suction

Other suggested mnemonic: MARBLESx2 or SOAP-ME

Assess airway upon patient arrival. Use mnemonic LEMONS

Principle reservoir - functional residual capacity (FRC) ~ 30ml/kg

Given 3 minutes before the induction agents and succinylcholine

Apply ABC principle

B Brain, increased ICP Use lignocaine or fentanyl

Cardiovascular, IHD, hypertension,

4. Paralysis with induction

Ketamine 2mg/kg Good bronchodilator, used Increased

Very cardiostable, used in

Neuromuscular blocking agent:

Test for patient's jaw for flaccidity

6. Placement with proof

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