Rapid Sequence Intubation

Procedure Info

When I was an intern, an ER nurse taught me that the way to remember the sequence of medications in a RSI is to know that “you date before you suck.” It sounded very graphic but was memorable.

Induction and Paralysis Medications

1) Etomidate 0.3mg/kg for induction of sedation.
-Usual dose is 20mg IV

2) -Rocuronium 1mg/kg as paralytic
-Usual dose is 70mg IV (for a 70kg person).
OR
–Succinylcholine 1-2 mg/kg as paralytic. It works faster than rocuronium and is preferred unless the patient has a neuromuscular disease or hyperkalemia.
-Usual dose is 100mg  (for a 70kg person if you use 1.5mg/kg)

It takes about 45 minutes (check and confirm) for the rocuronium and succinylcholine to wear off.
** Note that you are trying to paralyze the patient, you need to give enough medication to paralyze the patient. However, it is not a big deal if you for example, instead of giving 1.5mg/kg of succinylcholine, you instead gave 2mg. You can’t really paralyze them more, they are already paralyzed.

Equipment

Blade size:
Mac 4 for a male patient
Mac 3 for a female patient
Mnemonic – Mac is like an apple and is curved.
The other blade type is the Miller which is straight.
**If you need to lift to visualize the Lift in the direction of the handle of the blade, not up.

With a Miller which is straight, you pick the epiglottis up. With a Mac which is curved, you ________________

Tube size:
8.0-8.5 mm internal diameter for males
7.0-8.0 mm internal diameter for females
You want to insert the largest tube size possible for the patient, why? It will allow for a larger airway and also, if necessary, the patient can be scoped through it.
Note: If the tube is too small, the seal with not be good. If it’s

The Seven P’s of RSI

Preparation
Preoxygenation
Pretreatment
Paralysis with induction
Protection and positioning
Placement with proof
Postintubation management

The Intubation Process

  • You stand at the head of the bed.
  • Patient is appropriately positioned.
  • You hold the blade in your left hand.
  • Move the tongue with your blade to your left side to allow you to visualize where to put the tube.

More Equipment

  • Meds above
  • Bag Mask
  • Suction

 

Resources:


Using the Glidescope to intubate a patient

-Bougie for intubation.

http://emedicine.medscape.com/article/80222-overview
https://www.uptodate.com/contents/rapid-sequence-intubation-for-adults-outside-the-operating-room

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