Rapid Sequence Intubation: BY Budak Kecik

Rapid Sequence
Intubation
BY
BUDAK KECIK
DEFINITION
Intubation is the process of inserting a tube, called an

endotracheal tube, through the mouth and then into the
airway. This is done so that a patient can be placed on a
ventilator to assist with breathing.
INDICATIONS
A. GCS <8, quickly deteriorating GCS or loss of airway protection
B. Trauma with significant facial trauma and poor airway control
C. Burns with suspected inhalation/airway injury e.g laryngoedema/spasm
D. Respiratory exhaustion (CHF, COPD, Asthma: Attempt BiPAP first if

available:
example settings 12 cm inspiratory pressure, 5 cm H20 PEEP)
E. Hypoxia
F. Transport, if clinical deterioration is a possibility during transport e.g

psychotic pt
G. Severe sepsis (can reduce acidosis by reducing respiratory efforts)
PREPARATION
A. Place cardiac monitor, BP, continuous

O2 sat, 2 large-bore IVs.
B. Bag-valve-mask (BVM), nasal cannula

and nasal/oral airway.
C. Endotracheal tube (ETT) (Size 7.0,7.5

women and 8.0,8.5 men): inflate/deflate
cuff to check for leaks, insert stylet into
ETT and slightly kink the tip like a hockey
stick, apply lubricant jelly on tip of ETT.
G. Medications are ready.
H. Position head in sniffing position (folded towels or

pillow under head).
I. Remove dentures; assess if difficult intubation (anticipate

that all are difficult).
D. Laryngoscope of appropriate size

(curved blade 3-average, or 4-large),
check that light is functioning well.
E. Suction (Yankauer and catheter), BVM
plugged to 02, oral/nasal airways on
standby, C02 detector (colourmetric or
end-tidal).
F. Have difficult intubation kit nearby (Videoscope eg:

Glidescope or other), LMA, bougie, combitude,
cricothyroidotomy kit).
J. Protective gear/goggles/mask for doctor.

K. Prepare settings for ventilator if available.
L. Material to fix ETTube (pink tape, trach ties or fixator).
EQUIPMENT TRAY
Gloves:
The rescuer should at all times avoid direct contact with the
blood and other body fluids of the patient. If available, gloves
should be worn during all airway management procedures.
Suction:
In most resuscitation situations, the patient will either vomit,
or at the very least, will have an excess of secretions in their
oropharynx. If available, a suction catheter should be included
as part of your basic airway equipment.
EQUIPMENT TRAY
Lubrication:
The tip of the endotracheal tube should be lubricated prior to
insertion. Xylocaine jelly is a good lubricant because it
reduces irritation due to its local anesthetic effect.
Oropharyngeal airway:
In basic airway management, the oropharyngeal airway is
used to provide a patent airway to facilitate chest ventilation.
In advanced airway management, it can be inserted following
endotracheal intubation to act as a bite-block to protect the
endotracheal tube.
EQUIPMENT TRAY
Laryngoscope:
The laryngoscope handle and blade are used to elevate the
tongue and mandible to allow visualization of the cords. The
blade can be straight (Miller) or curved (Macintosh). Most
physicians use a Macintosh blade for adults. The blade must
be long enough to reach the vallecula (the space between the
base of the tongues and the epiglottis).
Bag-valve ventilator
EQUIPMENT TRAY
Mask:
Stylet:
A stylet can be inserted inside an endotracheal tube to make it more
rigid, or to change the shape of the tube. It is recommended that the
stylet be used in all emergency intubations. In this way, if the shape of
the tube needs to be modified, the stylet is already in place. The stylet
should be lubricated prior to insertion into the endotracheal tube, so
that it is easy to remove.
EQUIPMENT TRAY
Syringe:
Endotracheal tubes used in adults have an inflatable cuff near the tip.
The cuff, once inflated, is intended to seal the airway from aspiration
of oropharyngeal contents, and to prevent air leaks during positive
pressure ventilation. A 10 cc syringe should be included on the
aspiration tray to inflate the cuff of the tube with 5-10 cc's of air.
Endotracheal tube:
A properly positioned endotracheal (ET) tube will protect the airway
from aspiration and greatly facilitate bag-valve ventilation. An adapter
at the proximal end allows attachment to a bag-valve ventilator or
mechanical ventilator. The internal diameter of the cuff is printed on
the side of the ET tube. A 7.5 mm ET tube would be used in an
average-sized adult female, and an 8.0 mm ET tube in an averagesized male. The ET tube is also marked in cm to show how far the tube
has been advanced into the trachea.
EQUIPMENT TRAY
Tape:
Stethoscope
PRE-TREATMENT (TIME TO INTUBATION: 7

MIN)
Pre-oxygenation: Give patient 100% FiO2 non-rebreather mask (and consider added
nasal canula/airway with high flow 02) for 3 to 5 minutes. If patient requires immediate
intubation, give 5-8 BVM breaths and do not delay.
Keep patient in sitting-up position if possible, to improve air entry until ready
to intubate.
If suspect difficult intubation, keep the nasal canula/airway with high flow 02
(15L) even during intubation. This will help with passive oxygenation and prevent
desaturation during intubation.
Optional: Consider Fentanyl 50 mcg IV as pretreatment to decrease pain related
to intubation and to avoid elevation of intracranial hypertension. Do not give if
hypotensive.
INDUCTION MEDICATION (TIME TO INTUBATION: -2

MIN)
INDUCTION MEDICATION (TIME TO INTUBATION: -2

MIN)
PARALYSIS (TIME TO INTUBATION: -1

MIN)
Give immediately after the induction agent.
Pretreatment with a nondepolarizing neuromuscular blocking agent,

such as rocuronium, is no longer recommended.
Paralysis will increase the success rate of intubation. However, it is the

physicians responsibility to assess the benefit vs risk of intubation and
paralysis.
Assess for difficult airway, and for any difficulty in Bag Valve Mask
ventilation, prior to paralysis and intubation

MIN)

MIN)
INTUBATION (TIME: 0 MIN)
Application of back-up-right-pressure (BURP) on thyroid

cartilage by an assistant may help bring vocal cords into view.
B. Tilt head back with right hand (NOT if in C-Spine precaution:

jaw thrust only. Collar can be removed if another professional is
holding the c-spine secure). Insert, hold and pull the
laryngoscope (or videoscope) in left hand with a forward
motion; suction with right hand if needed; find the vocal
chords. Then introduce ETT with stylet using right hand.
C. Insert and visualize ETT cuff passing through the vocal cords
and remove stylet.
INTUBATION (TIME: 0 MIN)
If fail to view ETT going through vocal cords:

reposition and reattempt; if fail again: remove
ETT and bag patient. Start difficult intubation
options, as per physician preference:
a. Videoscope (eg Glidescope), if available
b. Bougie:
i. Insert tip, aiming up, along epiglottis

and advance.
ii.If you sense the tracheal rings until

resistance is felt, the bougie is placed
correctly. Insert ETT over bougie to
appropriate depth and remove Bougie.
iii. If resistance is not felt, the bougie

is in the esophagus, then remove it
immediately.
c. Laryngeal mask airway (LMA)
d. Combitube
e. Cricothyroidotomy (Needle or Surg
CONFIRMATION:
Check tube placement immediately after intubation.
B. Check air entry bilateral lung fields and that no air sounds are heard
in epigastric region.
C. Inflate ETT cuff with 5-10 cc air, or until little balloon slightly tense.
D. Secure ETT with tape, ties or fixator devices.
E. Maintain appropriate depth at lips or teeth:
a. 20-21cm at teeth for women
b. 22-23cm for men
CONFIRMATION:
. If patient is desaturating and having bradycardia, this indicates possible

esophageal intubation. Consider DOPE:
a. Displaced in Right mainstem bronchus or esophagus.
b. Obstruction (kinked, bitten, mucous).
c. Pneumothorax.
d. Equipment problem or in Esophagus.
POST-INTUBATION MANAGEMENT
A. Monitor patient closely, including vital signs and

responsiveness.
B. If patient is hypotensive:
a. Give NS fluid bolus(es)
b. Phenylephrine PRN (if available)
i. Safe to give small push doses via peripheral IV
ii.To prepare: Take 1ml (1amp) of the 10mg(10000mcg)/ml

1% and dilute it in a 100ml NS bag; each 1 ml of this diluted
solution now contains 100mcg of phenylephrine
(100mcg/ml).
iii. Give small dose of 100mcg (1ml) IV push bolus at a time.
C. Sedation maintenance perfusions:
a. Prepare prior to intubation if possible.
b. Start low and titrate up to response.
c. Additional bolus may be given if patient wakes or gets agitated

which is common if succinylcholine is used.
e. Two medications are often combined (eg benzo+analgesic).
Elevate head of bed 30 degrees if possible (reverse

Trendelenburg if patient needs C-spine precautions).
Check periodically that ETT remains secure and positioned at

appropriate depth.
Do stat portable CXR if available, to:
a. Assess tube depth and placed 2cm above carina.
b. Rule out right mainstem bronchus intubation.
c. Rule out pneumothorax.
d. Tip should be below claviclular line.
VENTILATOR (IF AVAILABLE)
Initial settings:
A. Assist/Control or SIMV mode (or bag).
B. Begin with 100% Fi02, then titrate down to maintain

adequate 02 saturation.
C. Tidal volume 10ml/kg of ideal weight (average 600-700ml).
D. Resp rate 10-12 breaths/min (correlate clinically and with

blood gases results).
E. Inspiration/expiration ratio 1:2 (1:3 if bad asthma/COPD).
F. PEEP 5cm H20.
G. Inspiration flow rate 60L/min.
H. Goal: Keep inspiratory peak pressure under 35cm H20.
BLOOD GAS GOALS
If available, check 30 min. after intubation. Venous blood gas is

sufficient, but
arterial blood gas is preferred.
A. pH 7.35-7.45
B. Pa02 60-90mmHg (if arterial gas)
C. PaCO2 40mmHg (venous or arterial gas)
D. O2 saturation
a. Titrate to keep above 92% if no arterial blood gas

available
b. Titrate down Fi02 if possible (example: titrate from

100% down to 21- 40% Fi02)

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Rapid Sequence

Intubation is the process of inserting a tube, called an

A. GCS <8, quickly deteriorating GCS or loss of airway protection

B. Trauma with significant facial trauma and poor airway control

C. Burns with suspected inhalation/airway injury e.g laryngoedema/spasm

D. Respiratory exhaustion (CHF, COPD, Asthma: Attempt BiPAP first if

F. Transport, if clinical deterioration is a possibility during transport e.g

G. Severe sepsis (can reduce acidosis by reducing respiratory efforts)

A. Place cardiac monitor, BP, continuous

B. Bag-valve-mask (BVM), nasal cannula

C. Endotracheal tube (ETT) (Size 7.0,7.5

G. Medications are ready.

H. Position head in sniffing position (folded towels or

I. Remove dentures; assess if difficult intubation (anticipate

D. Laryngoscope of appropriate size

F. Have difficult intubation kit nearby (Videoscope eg:

J. Protective gear/goggles/mask for doctor.

L. Material to fix ETTube (pink tape, trach ties or fixator).

PRE-TREATMENT (TIME TO INTUBATION: 7

INDUCTION MEDICATION (TIME TO INTUBATION: -2

INDUCTION MEDICATION (TIME TO INTUBATION: -2

PARALYSIS (TIME TO INTUBATION: -1

Give immediately after the induction agent.

Pretreatment with a nondepolarizing neuromuscular blocking agent,

Paralysis will increase the success rate of intubation. However, it is the

PARALYSIS (TIME TO INTUBATION: -1

PARALYSIS (TIME TO INTUBATION: -1

INTUBATION (TIME: 0 MIN)

Application of back-up-right-pressure (BURP) on thyroid

B. Tilt head back with right hand (NOT if in C-Spine precaution:

INTUBATION (TIME: 0 MIN)

If fail to view ETT going through vocal cords:

a. Videoscope (eg Glidescope), if available

i. Insert tip, aiming up, along epiglottis

ii.If you sense the tracheal rings until

iii. If resistance is not felt, the bougie

c. Laryngeal mask airway (LMA)

e. Cricothyroidotomy (Needle or Surg

Check tube placement immediately after intubation.

D. Secure ETT with tape, ties or fixator devices.

E. Maintain appropriate depth at lips or teeth:

a. 20-21cm at teeth for women

b. 22-23cm for men

. If patient is desaturating and having bradycardia, this indicates possible

a. Displaced in Right mainstem bronchus or esophagus.

b. Obstruction (kinked, bitten, mucous).

d. Equipment problem or in Esophagus.

A. Monitor patient closely, including vital signs and

a. Give NS fluid bolus(es)

b. Phenylephrine PRN (if available)

i. Safe to give small push doses via peripheral IV

ii.To prepare: Take 1ml (1amp) of the 10mg(10000mcg)/ml

iii. Give small dose of 100mcg (1ml) IV push bolus at a time.

C. Sedation maintenance perfusions:

a. Prepare prior to intubation if possible.

b. Start low and titrate up to response.

c. Additional bolus may be given if patient wakes or gets agitated

e. Two medications are often combined (eg benzo+analgesic).

Elevate head of bed 30 degrees if possible (reverse