Rapid sequence induction, and check out Rapid sequence induction on Wikipedia, Youtube, Google News, Google Books, and Twitter on Digplanet. Diagram showing the result of a successful RSI: an endotracheal tube (blue) inserted into the trachea (C), protecting the lungs from regurgitation through the esophagus (D). Rapid sequence induction, also described as rapid sequence intubation (RSI), is an advanced airway management medical procedure used to achieve tracheal intubation under general anesthesia in patients who are at high risk of pulmonary aspiration. The induction drugs traditionally used for RSI have short durations of action, wearing off after only minutes. Rapid sequence intubation refers to the pharmacologically induced sedation and neuromuscular paralysis prior to intubation of the trachea. The aim of preoxygenation is to replace the nitrogen that forms the majority of the functional residual capacity with oxygen.
Newer methods of pre oxygenation include the use of a nasal cannula placed on the patient at 15 LPM at least 5 minutes prior to the administration of the sedation and paralytic drugs. Pretreatment consists of the medications given to specific groups of high-risk patients 3 minutes before the paralysis stage with the aim of protecting the patient from the adverse effects of introducing the laryngoscope and endotracheal tube. With standard intravenous induction of general anesthesia, the patient typically receives an opioid, and then a hypnotic medication. The Sellick's maneuver, or cricoid pressure, may be used to occlude the esophagus with the goal of preventing aspiration.
The position of the tube in the trachea can be confirmed in a number of ways, including observing increasing end tidal carbon dioxide, auscultation of both lungs and stomach, chest movement, and misting of the tube.
Malpositioning of the endotracheal tube (in a bronchus, above the glottis, or in the esophagus) should be excluded by confirmation of end tidal CO2, auscultation and observation of bilateral chest rise. Age can play a role in whether or not the procedure is warranted, and is commonly needed in younger persons.[10] The clinician that performs RSI must be skilled in tracheal intubation and also in bag valve mask ventilation. RSI is mainly used to intubate patients at high risk of aspiration, mostly due to a full stomach as commonly seen in a trauma setting. If the patient on initial assessment is found to have a difficult airway, RSI is contraindicated since a failed RSI attempt will leave no option but to ventilate the patient on bag and mask which can lead to vomiting. RSI involves pre-filling the patient's lungs with a high concentration of oxygen gas, followed by administering rapid-onset hypnotic and neuromuscular-blocking drugs that induce prompt unconsciousness and paralysis, allowing insertion of an endotracheal tube with minimal delay.

This confers a degree of fault tolerance on the procedure when it is used in elective or semi-elective settings: if intubation is unsuccessful, and if the clinical condition allows it, the procedure may be abandoned and the patient should regain the ability to protect their own airway sooner than would be the case under routine methods of induction.
This provides an oxygen reservoir that will delay the depletion of oxygen in the absence of ventilation (after paralysis) for up to 8 minutes (to an oxygen saturation of 90%) in the healthy adult.[2] This time will be significantly reduced in obese patients, ill patients and children. High flow nasal oxygen has been shown to flush the nasopharynx with oxygen, and then when patients inspire they inhale a higher percentage of inspired oxygen. Intubation causes increased sympathetic activity, an increase in intracranial pressure and bronchospasm. Generally the patient will be manually ventilated for a short period of time before a neuromuscular blocking agent is administered and the patient is intubated.
Commonly used neuromuscular blocking agents used include succinylcholine and rocuronium.[6] The neuromuscular blocking agents paralyze all of the skeletal muscles, most notably and importantly in the oropharynx, larynx, and diaphragm. 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. Alternative airway management devices must be immediately available, in the event the trachea cannot be intubated using conventional techniques. Preoxygenation causes distention of stomach which can induce vomiting, so this phase must be quick.
This is a control, companion video to the Homerton RSI checklist video to be launched in 2015. Traditionally, unlike other methods of anaesthesia induction, no artificial ventilation is provided from the time that drugs are administered until after intubation has been achieved; this minimises insufflation of air into the stomach, which might otherwise lead to regurgitation.
Conversely, in emergency settings where the patient's condition does not allow for them to be woken up immediately, a failed intubation under RSI places them at very high risk for respiratory compromise. The equipment and drugs for the intubation are planned, including the endotracheal tube size, the laryngoscope size, and drug dosage. Small changes in FiO2 create dramatic changes in the availability of oxygen at the alveolus, and these increases result in marked expansion of the oxygen reservoir in the lungs prior to the induction of apnea. Patients with reactive airway disease, increased intracranial pressure, or cardiovascular disease may benefit from pretreatment. Opioids such as fentanyl may be given to attenuate the responses to the intubation process (accelerated heart rate and increased intracranial pressure).

The sniffing position is achieved by placing a rolled towel underneath the head and neck, effectively extending the head and flexing the neck. For the same reason, cricoid pressure may also be used until after the tube has been secured. After apnea created by RSI the same high flow nasal cannula will help maintain, or even increase, oxygen saturation during efforts securing the tube (oral intubation). However, the difference lies in the fact that the induction drug and neuromuscular blocking agent are administered in rapid succession with no time allowed for manual ventilation. This is supposed to have advantages in patients with ischemic heart disease and those with brain injury (e.g. Invasive techniques such as cricothyrotomy must also be available in the event of inability to intubate the trachea by conventional techniques. Intravenous access is obtained to deliver the drugs, usually by placing one or two IV cannulae.
Lidocaine has the ability to suppress the cough reflex which in turn may mitigate increased intracranial pressure.
Laryngoscope blades and endotracheal tubes smaller than would be used in a non-emergency setting are selected. For this reason Lidocaine is commonly used as a pretreatment for trauma patients who are suspected of already having an increase in intracranial pressure. Lidocaine is also theorized to blunt a rise in intracranial pressure during laryngoscopy, although this remains controversial and its use varies greatly.
Although there is not yet definitive evidence to support this, if proper dosing is used it is safe. Atropine may be used to prevent a reflex bradycardia from vagal stimulation during laryngoscopy, especially in young children and infants.

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Rubric: Canada Emergency Preparedness


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