EMS Medication Administration - RSI Endotracheal Intubation

EMS Providers should have a comprehensive understanding of rapid sequence endotracheal intubation (RSI) medication administration to ensure successful and safe management of patients requiring advanced airway interventions.

Here are some points they should know:

1. Indications and Goals

Indications:

• To facilitate endotracheal intubation (ETI) in patients who require definitive airway management.
• Medications administered during intubation typically include induction agents (sedatives) and neuromuscular blocking agents (paralytics) and analgesics (pain relievers).

Goals:

• Achieve rapid sedation and paralysis to facilitate smooth intubation without causing harm or distress to the patient.
• Ensure patient comfort and safety throughout the procedure.

2. Medications Used

Analgesic Agents:

• Fentanyl: EMS Providers should consider opioid administration to intubated patients, as NMBAs and sedatives do not relieve the pain associated with intubation and positive pressure ventilation (Fatolitis, 2022).

Induction Agents:

• Etomidate: Rapid onset sedative with minimal cardiovascular effects.
• Propofol: Potent sedative with rapid onset and short duration of action.
• Ketamine: Dissociative agent providing sedation, analgesia, and amnesia.
• Midazolam: Benzodiazepine used for sedation, less commonly for induction due to slower onset.

Neuromuscular Blocking Agents (NMBAs):

• Succinylcholine: Depolarizing agent for rapid paralysis.
• Rocuronium / Vecuronium: Non-depolarizing agent with longer duration of action and less side effects compared to succinylcholine.

3. Preparation and Technique

Medication Preparation:

• Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
• Calculate and prepare appropriate doses based on patient weight and condition.

Procedure Preparation:

• Ensure all equipment for intubation is ready and functional (e.g., laryngoscope, endotracheal tube, suction).
• Confirm patient positioning, secure environment, and adequate personnel for assistance.

4. Administration Techniques

Induction Agent Administration:

• Administer induction agents rapidly to achieve sedation and facilitate intubation.
• Ensure titration of medications to achieve desired sedation level without compromising hemodynamics.

Neuromuscular Blocking Agent Administration:

• Administer NMBAs after confirming adequate sedation to prevent patient awareness and facilitate intubation.
• Monitor for onset of paralysis and ensure proper ventilation during apnea phase.

5. Monitoring and Management

Monitoring:

• Continuously monitor vital signs including heart rate, blood pressure, oxygen saturation, and ECG if possible.
• Monitor level of sedation and depth of paralysis to adjust as necessary.

Management:

• Be prepared to manage potential complications such as hypotension, respiratory depression, or adverse reactions to medications.
• Have reversal agents available if needed (e.g., naloxone for opioid-induced respiratory depression).

6. Post-Intubation Care

Securing the Airway:

• Confirm proper placement of the endotracheal tube (ETT) using clinical and adjunctive methods (e.g., end-tidal CO2 monitoring).
• Secure the ETT and confirm effective ventilation.

Continued Monitoring:

• Maintain continuous monitoring of vital signs and oxygenation.
• Prepare for transport to appropriate medical facility, ensuring ongoing airway management and support.

7. Special Considerations

Pediatric and Geriatric Patients:

• Adjust medication doses and techniques based on age, weight, and physiological differences.

Difficult Airway Management:

• Be prepared for difficult intubations and have backup plans in place (e.g., alternative airway devices, surgical airway equipment).

Patient Condition:

• Consider comorbidities and potential contraindications to specific medications based on patient history.

8. Training and Proficiency

Simulation Training:

• Regular practice in simulated scenarios to maintain proficiency in intubation medication administration and airway management techniques.

Continuing Education:

• Stay updated on current guidelines, best practices, and new medications relevant to intubation and airway management.

9. Legal and Ethical Considerations

Scope of Practice:

• Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent:

• Obtain informed consent from the patient or guardian whenever possible, considering the urgency and necessity of the procedure.

Documentation:

• Accurate documentation of medication administration, intubation process, airway assessment, and ongoing patient monitoring.

Conclusion

Medication administration for RSI is a critical skill for EMS Providers performing advanced airway management. It requires proficiency in medication administration, airway assessment, and management of potential complications.

Continuous training, adherence to protocols, and effective teamwork are essential for ensuring successful patient outcomes in emergency situations.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins

Fatolitis, N. (2022) Keys To Success For Airway Management. EMS Airway. https://emsairway.com/.../keys-to-success-for-airway.../... Accessed July 26, 2024

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Nickson, C. (2024) Rapid Sequence Intubation (RSI). Life In The Fast Lane. https://litfl.com/rapid-sequence-intubation-rsi/ Accessed July 26, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell