Airway Part 3- Rapid Sequence Intubation
EM Clerkship
Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD
4.9 • 816 Ratings
🗓️ 27 January 2019
⏱️ 14 minutes
🧾️ Download transcript
Summary
The most important thing to do when preparing for RSI is to PREOXYGENATE the patient.
Step 1: Choose Your Equipment
* Miller or Mac blade? * Miller blade is straight (like the ‘L’ in miller)* Frequently used in kids* Mac blade is curved (like the ‘c’ in mac)* (Generally, this is the best choice to use on your clerkship and most common in the ED)* Tube Size?* 7.5 cuffed tube for a small adult* 8.0 cuffed tube for a big adult
Step 2: Choose your Meds
* You need both a sedative and a paralytic to perform RSI* Paralytic options are succinylcholine or rocuronium* Succinylcholine is best if you need something short acting* For example, when frequent neurologic checks are required* Rocuronium is best because it’s easy to remember (1mg/kg)* “Rocuronium Rocks”* Sedative options include ketamine, propofol, and midazolam. * My favorite is ETOMIDATE. * It is hemodynamically neutral.* Dosing is 0.3mg/kg
Step 3: Prepare Your Equipment
* Suction* Bag Valve Mask* Backup airway (ex. LMA)* Cardiac monitor* Capnography for tube placement
Step 4: DO IT
* Push the sedative* Push the paralytic* Put the blade in your LEFT hand* Open mouth with right hand* Slowly advance (holding top of blade against tongue) until you see cords* The cords will be hiding under the white, cartilaginous, tongue-like epiglottis
NOTE: It’s OK if you don’t get it. It happens and it won’t make you look bad if your form was otherwise great.
Step 5: Advance the Tube and then CLOSING STATEMENT
* Generally, you want depth to equal 3x the size of the tube* Closing statement* “Please attach capnography to confirm tube placement”* “We will need to get an X-ray, foley, OG tube and start the patient on propofol (or versed)”
CONGRATULATIONS!! THEY ARE INTUBATED!!
Transcript
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| 0:00.0 | Hello, med students. My name is Zach Olson, and thank you for downloading this week's episode of the E.M. Clerkship Podcast. This week, we are talking finally about the tube. So airway phase one, right, was suction and move the tongue. And then phase two was how to oxygenate with a bag valve mask. And when you have trouble, the tricks that you have up your sleeve, the nasal pharyngeal, oropharyngeal, LMA, king, combative. You got to master that. But we've now arrived at this week. |
| 0:40.4 | How to intubate. |
| 0:45.2 | It's called rapid sequence intubation, RSI. |
| 0:51.6 | Once you got that patient oxygenated, once you got their blood pressure somewhat stable, and you've suction and you've moved the tongue you've used that bag valve |
| 0:56.5 | mask or any adjuncts if necessary obviously you don't use them if they're not necessary but you want |
| 1:01.6 | to get them oxygenated now you can start thinking about intubation i'm not going to teach this how |
| 1:08.3 | the book teaches it the The peas, right? |
| 1:11.1 | You prep and then you pre-oxygenate and you position and you pre-treat and then you paralyze |
| 1:17.9 | and then you pray and then you pass the tube and then post-treatment or whatever. |
| 1:22.8 | Like there's like a million peas, right? |
| 1:24.5 | Because I can't really remember it. |
| 1:26.5 | I think it's dumb. |
| 1:28.8 | The most important part of intubation is that you need to pre-oxygenate the moment you start going down this pathway, |
| 1:34.8 | you want to have the patient have a non-or breather on or a bipap. You want to basically just |
| 1:40.3 | flood them with oxygen. This is really the only time where you want to do that, but you |
| 1:45.4 | want to flood them with oxygen. This buys you time to do the RSI procedure without their |
| 1:51.6 | oxygen level dropping really, really dangerously low. And so the more oxygen, you can kind of |
| 1:57.2 | pre-oxygenate into their lungs up front, and the more nitrogen you can wash out |
| 2:03.5 | the longer you can attempt and re-attempt without your attending, ending your attempt, and taking |
| 2:12.0 | the blade away because the monitor's beeping and the patient's desaturated. |
| 2:17.3 | It buys you time. You want to pre-oxygenate |
| 2:20.0 | the shit out of your patient. That is the main thing to know. But after that, today, the procedure, |
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