Rapid Response Intubation (Adult)

Rapid Sequence Intubation (Adult)

RSI Indications

GCS < 10 due to:
Primary Neurological Injury - Traumatic brain injury (TBI) - Non-traumatic brain injury - Stroke/Subarachnoid haemorrhage (see RSI Special Notes)	Overdose with any of: - Suspected tricyclic antidepressant O/D - Difficult extrication - Prolonged transport time (>30min) - O2 sat. unable to be maintained >90% (see RSI Special Notes)

Hypoxic brain injury
- Post-hanging, near drowning
- ROSC

Status epilepticus
(see RSI Special Notes)

Severe hyperthermia
- >39.5°C despite 10min of management
(see RSI Special Notes)


General Precautions
Time to intubation at hospital versus time to intubate at scene
Poor baseline neurological function and major co-morbidities
Advanced Care Plan / Refusal of Medical Treatment document specifies“Not for Intubation”

Anticipation of difficulty with BVM ventilation
Anticipation of a difficult intubation, e.g. morbid obesity, short neck or facial trauma

RSI Precautions
In general if transport time <10min then no RSI


RSI Contraindications
Clinical situations where failed intubation drill would not be feasible
No functional electronic capnograph
Any contraindications to Suxamethonium
Coma due to uncontrolled bleeding (see RSI Special Notes)


General Preparations
Position Pt. If a cervical collar is fitted it should be opened while maintaining manual cervical support
Pre-oxygenate with 100% O2 and electronic capnograph attached
Ensure pulse oximeter and cardiac monitor are functional
Prepare equipment and assistance - Suction - ETT (plus one size smaller than predicted immediately available) with introducer - Oesophageal Detector Device (ODD). - Ensure equipment for a difficult / failed intubation is immediately available, including bougie, LMA, cricothyroidotomy kit - Mark cricothyroid membrane as necessary - Brief assistant to provide cricoid pressure, where appropriate - If suspected spinal injury, where possible a second assistant should be available to stabilise the head and neck
Ensure functional and secure IV access


RSI Preparations
Pre-hydrate with Normal Saline fluid bolus 10 ml/kg IV
If Pt hypotensive and/or tachycardic, follow relevant CPG in conjunction with the intubation process
Adrenaline not to be given in Hypovolaemic shock
Draw up and label drugs as appropriate

RSI Drugs

Fentanyl /Midazolam as below:

Adjusted sedation dose required

AGE	BP	HR	TBI	Fentanyl	Midazolam
<60	>100	<100	-	100 mcg IV	0.1 mg/kg IV (max 10mg)
		>100	No	100 mcg IV	0.1 mg/kg IV (max 10mg)
		>100	Yes	50 mcg IV	0.05 mg/kg (max 5 mg)
	80-100	<100	-	50 mcg IV	0.05 mg/kg (max 5 mg)
	<80	-	-	25-50 mcg IV	1 mg IV only

>60	>80	-	-	50 mcg IV	0.05 mg/kg (max 5 mg)
>60	<80	-	-	25-50 mcg IV	1 mg IV only

Pt Bradycardic at any stage:

Atropine 600mcg IV

Paralysing Agent:

Suxamethonium 1.5 mg/kg IV


RSI Drugs - Special Notes
Sedation doses for RSI are based on initial observations. This is especially important in multi-trauma with TBI. Initial fluid challenges may resolve tachycardia and/or hypotension, however the Pt is still at risk of cardiovascular compromise and the blood pressure must be strenuously supported. Half doses (or less) of sedation are required in this situation.
In Pts with extremely poor perfusion, treat with fluid therapy +/- Adrenaline infusion concurrently with RSI. Consider quarter doses of sedation.


Insertion of ETT
Observe passage of ETT through cords noting AS standard markings and grade of view
Check ETT position using Oesophageal Detector Device (ODD).
Inflate cuff.
Confirm tracheal placement via capnography (note: Pt in cardiac arrest may not have EtCO2 initially detectable).
Exclude right main bronchus intubation by performing the cuff palpation (“tracheal squash”) test and by comparing air entry at the axillae.
Note length of ETT at lips/teeth.
Cuff Palpation
Auscultate chest/epigastrium - Chest rise and fall, bag movement, SpO2, colour, tube misting
Note supplemental cues of correct placement (e.g. tube “misting”, bag movement in the spontaneously ventilating Pt, improved oxygen saturation and colour).
Secure the ETT and insert a bite block if required.
If there is ANY doubt about tracheal placement, the ETT must be removed
If unable to intubate after ensuring correct technique and problem solving, then proceed to Failed Intubation Drill


Successful Intubation?

Yes

Failed Intubation Drill

Cricothyroidotomy

Does Pt's require sedation or paralysis to maintain intubation and ventilation?

Yes

Post Intubation Sedation

Post Intubation Paralysis

Restlessness/signs of under sedation in the absence of other noxious stimuli
- e.g. ETT too deep/irritating, occult pain

Prevention of shivering for Pts receiving therapeutic cooling

Primary Neurological Pts

Where sedation alone is ineffective at maintaining intubation or allowing adequate ventilation / oxygenation

As prescribed for interhospital transfer

All Pts receiving paralysis MUST receive ongoing sedation

The ETT must be secured and tracheal placement reconfirmed with electronic capnography

C/I for Pt in Status epilepticus

Sedate as per Post Intubation Sedation

Pancuronium 8mg IV
- Repeat if evidence of returning muscular activity
(movement, chewing, cough, gag, curare cleft)

Signs of inadequate sedation
Non Paralysed:
- As per Paralysed
- Cough/gag/movement up together
Pt Paralysed Pt:
- HR and BP trending
- Tearing
- Diaphoresis

Morphine/Midazolam infusion 1 - 10mg/hr IV
- 0.5mg - 5mg IV boluses as required

Until Morphine/Midazolam infusion established:
- Midazolam 0.5mg - 5mg IV as required or
- Midazolam/Morphine 0.5mg - 5mg IV each drug

Care / Ventilation of the Intubated Pt
ETT checks with each Pt movement
Provide circulatory support if hypotension present
Use colourimetric capnometry if capnography fails
Suction ETT and oropharynx
Insert OG/NG tube
Ventilate VT 10ml / per kg, EtCO2 30 - 35mmHg if appropriate to Pt condition
Disconnect and hold ETT during transfers
Specific instructions as per General Care of the Intubated Pt

General Care
Reconfirm tracheal placement using EtCO2 after every Pt movement. Disconnect and hold ETT during all transfers.
If electronic capnography fails after intubation, use colourimetric capnometry.
Suction ETT and oropharynx in all Pts.
If time permits, insert orogastric or nasogastric tube, aspirate and connect to drainage bag. The orogastric route must be used in head or facial trauma.
Ventilate using 100% oxygen and tidal volume of 10 ml/kg. Aim to maintain SpO2 > 95% and EtCO2 at 30 - 35mmHg (except asthma / COPD where a higher EtCO2 may be permitted, tricyclic OD where the target is 20 - 25mmHg, and DKA where the EtCO2 should be maintained at the level detected immediately post-intubation, with a max. of 25mmHg).
Document all checks and observations made to confirm correct ETT placement.

RSI Special Notes

Primary Neurological Injury
- RSI should be provided unless Pt is in cardiac arrest. This includes Pts with absent airway reflexes.
- Midazolam should not be used to control combativeness prior to RSI in head injury. Judicious pain relief with narcotic should be used. If combativeness is preventing pre oxygenation (this is rare), then once all preparations have been made for RSI the Fentanyl should be given. This should settle the Pt sufficiently to enable pre oxygenation for 2-3min., then the Midazolam and Suxamethonium should be given and the Pt intubated.

Status epilepticus
- A continuous or recurrent seizure of 10min. duration or no return of consciousness between episodes may require intubation where there is airway/ventilation compromise which is unable to be effectively managed using BVM and OPA/NPA.

Suspected tricyclic antidepressant O/D
- Requiring hyperventilation for cardiac arrhythmia prevention or management

Overdose
- The intent of the OD (difficult extrication) indication for RSI is for the Pt to be intubated at the scene to enable safer extrication.

Uncontrolled bleeding
- In Pts with uncontrolled bleeding (e.g. ruptured AAA
ruptured ectopic pregnancy, penetrating truncal trauma, intra-abdominal trauma, limb avulsion), ongoing bleeding may lead to poor cerebral perfusion and coma.
- RSI in these Pts is potentially harmful. The sedation may drop blood pressure further and the added scene time increases total blood loss. The appropriate treatment for these Pts is urgent transport and immediate surgery.
- RSI should NOT be undertaken in Pts who become unconscious when the coma is likely to be secondary to blood loss, unless RSI is judged to be absolutely essential (unmanageably combative and / or impractical to transport unintubated). This applies to Pts being transported both by road and air Ambulance.
- Airway management with BVM is to be maintained in conjunction with prompt transport. Intubation (without drugs) should be considered if airway reflexes are lost, bearing in mind the risks of delay to definitive surgical care.

Severe hyperthermia
- May result from drug OD or heat exposure. If after 10/60 of active cooling Pt temp. remains > 39.5°C and GCS < 10, then Pt should be intubated with RSI.