1	Introduction To Rapid Sequence Intubation (R.S.I.)
2	Topics of Discussion 1. What is Rapid Sequence Intubation 2. Anatomy of the Airway 3. R.S.I. Pharmacology 4. Six P’s to RSI 5. Case Review 6. Mark’s Five Tips for Intuabtion
3	What is Rapid Sequence Intubation By definition: A technique where a potent sedative or induction agent is administered virtually simultaneously with a paralyzing dose of neuromuscular blocking agent to facilitate rapid tracheal intubation. What does that mean to us? A lot of Documentation!!!!!!!!!!!!!
4	Who Requires R.S.I. Unable to maintain airway Unable to maintain ventilation's GCS<8 (less then 8 intubate) Status epilepticus Inability to handle secretions
5	Who Not to R.S.I. Epiglottitis patients Patients with severe facial trauma Paramedic not comfortable with procedure. Patients that can maintain an airway using non-evasive procedures
6	Anatomy of the Airway Soft Plate Oropharynx Epiglottis Vocal Cord Larynx Esophagus Trachea Turbinates Tongue Vallecula Thyroid Cart. Cricoid Membrane
7	Anatomy
8	R.S.I. Pharmacology Pre-medicating Agents medicate for underlying condition Induction Agents to induce deep sedation (anesthesia) Neuromuscular Blocking Agents depolarizes the muscles causing relaxation Post intubation medications to keep patient sedated to protect the tube
9	Pre-Medicating Agents
10	Induction Agents
11	Neuromuscular Blocking Agents
12	Post Intubation Medications
13	Five P’s to R.S.I. Pre-Oxygenate Preparation Pre-medicate Paralysis & Sedation Passing the tube & proof of tube placement Post-intubation management
14	Pre-Oxygenate Oxygenate patient for 3 to 5 minutes with high Flow 02 via Non-rebreather or Bag Valve Mask to increase the body’s oxygen reserves.
15	Preparation Paramedic performing this should be comfortable with the procedure Pre-Oxygenate Position patient Apply Cardiac Monitor Start IV Continuous Pulse Ox Make sure Intubation Equipment is ready Suction ready Prepare equipment for Needle Cricothyoidotomy if needed
16	Pre-medicate Pre-medicate patient for underlying illness or injury Head Injuries Children < 8 Bradycardia Other underlying conditions
17	Paralysis and Sedation Point of no return Make sure to give your medication the way they are meant to be given Make sure patient is sedated prior to paralysis Time your medication so that sedation and paralysis happens almost simultaneously Apply cricoid pressure (Sellick’s Maneuver)
18	Passing the tube & proof of tube placement Passing the tube Position yourself Position the patient Always us a stylet Laryngoscope left hand & Tube right hand visualize tube passing thru cords 3 times tube size equals proper tube depth Proof of Tube Placement Visualize tube passing thru Cords. Equal rise and fall of chest Good breath sounds X4 ETCO2 device Capnography
19	Post-intubation Management Secure Tube Document tube depth Reassess rise and fall of chest breath sounds Capnography Maintain Sedation sedating agents neuromuscular blocking agents
20	Case Review #1 Dispatched 1 Car MVA male subject ejected from vehicle Vehicle was traveling at high speed Mutli-Facial Truama with orbital fracture Unresponsive GCS 5 Resp. Rate 4 Heart Rate 160 B/P 130/P Pt weight approx.. 100 Kg
21	Case Review #1 Treatment C-Spine Precautions BVM Ventilation rate 24 with 15 lpm (poor compliance) Oral Airway attempted (unsuccessful do to gag reflex) Cardiac Monitor Two Large Bore IV TKO Lidocaine 100mg IVP Vecuronium 1mg IVP Succinylcholine 100mg IVP Etomidate 30mg IVP Intubated 2nd attempt with 7.5 ETT Depth 23mm Tube placement confirmed by Visualization of tube passing thru cords, ETCO2, and BS bilaterally with equal rise & fall of chest Patient boarded and transported to Level 1 Trauma center via helicopter.
22	Case Review #2 2 Car MVA with Entrapment car vs truck Car T-boned truck towing horse trailer Unrestrained driver with heavy damage to car Multi minor facial lacerations GCS 8 with doll eyes Skin pale, warm, and diaphoretic Resp 6 and shallow Heart Rate 180 radial pulses Possible right femur fracture
23	Case Review #2 Treatment C-spine precautions taken Patient rapidly extricated High flow 02 via NRB at 10 lpm 2 large bore IV TKO BVM ventilation at 24 with 15lpm poor compliance IV meds Lidocaine 100mg, Vecuronium 1mg, Etomidate 15mg, and Succinylcholrine 100 Pt Intubated 7.0 ETT tube depth 22mm Tube placement confirmed with visualize of tube passing thru cords
24	Case Review #2 Treatment Continued equal rise and fall of chest with good BSx4 Pt became bradycardiac at rate of 44 Atropine 1mg IVP Pt arrests CPR started Epi 1:10,000 1mg IVP Left chest needle decompression 1000cc fluid bolus given Pt pulse returned with radial pulses Pt boarded and transported to level 1 trauma center via helicopter
25	Case Review #3 Disposition 4 year old ATV rollover Pt presents in the back of a pickup truck prone Pt was ride in front of driver of ATV Pt is observed unresponsive with blood flowing from his right ear and nose Left side posturing Wheezes in left lobe right lobe clear Heart rate 60 Resp 16
26	Case Review #3 Treatment C-spine precautions taken (towel rolls) Pt boarded Unable to ventilate patient with BVM Pt jaw clinched Suctioned airway Unable to intubate due to clinched jaw IV started IV medications given Atropine 0.2mg, Lidocaine 20mg, Etomodate 6mg, and succinylcholine 40mg 10cc of blood suctioned from airway Intubated 5.O ETT tube depth 15 Tube placement confirmed with visualization of tube passing thru cords and equal rise and fall with BSx4
27	Case Review #3 Treatment continued Intubated 5.O ETT tube depth 15 Tube placement confirmed with visualization of tube passing thru cords and equal rise and fall with BSx4 Tube secured with ET tape along with manual securing Pt boarded and transported to Level 1 pediatric Trauma Center via helicopter
28	Mark’s 5 tips to intubation Position the patient Position Yourself Find the Prize Keep Yours Eyes on the Prize Sellick’s Maneuver
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