mark tozer's blog: EMS Airway Management - The 9 P’s of Rapid Sequence Intubation (RSI)

The 9 P’s of Rapid Sequence Intubation (RSI) is a systematic approach that EMS providers use to ensure the safe and effective management of airway control in critically ill or injured patients.

Here's what EMS providers need to know about each step:

1. Plan

Strategic Planning:
- Assess the need for intubation based on the patient's condition, such as respiratory failure, decreased level of consciousness, or impending airway compromise.
- Consider alternative airway management strategies in case RSI fails (e.g., supraglottic airway, surgical airway).
Backup Plan:
- Establish a clear plan for what to do if initial attempts at intubation fail, including calling for additional help or preparing for an alternative airway.

2. Preparation

Drugs:
- Prepare and draw up all necessary medications for induction (e.g., etomidate, ketamine) and paralysis (e.g., succinylcholine, rocuronium).
- Check drug dosages based on the patient’s weight and condition, and label syringes clearly.
Equipment:
- Ensure all airway equipment is ready, including laryngoscope blades, endotracheal tubes (ETTs) of various sizes, stylets, and backup devices like the iGel.
- Check the functionality of suction devices, bag-valve masks (BVMs), and capnography monitors.
People:
- Assign roles to team members, ensuring clear communication about who will administer medications, who will perform the intubation, and who will monitor the patient.
- Designate someone to manage the patient’s cervical spine if trauma is suspected.
Place:
- Prepare the environment by ensuring adequate space, lighting, and a stable surface for the procedure.
- Ensure that all necessary equipment and personnel are within reach.

3. Protect the Cervical Spine

Cervical Spine Precautions:
- If trauma is suspected, manually stabilize the cervical spine to prevent movement and further injury.
- Consider in-line stabilization while maintaining the cervical collar and minimizing neck movement during intubation.

4. Positioning

Optimal Positioning:
- Position the patient in the “sniffing” position, with the head slightly elevated and the neck extended, to align the oral, pharyngeal, and laryngeal axes for better visualization during intubation.
- In patients with suspected cervical spine injuries, maintain manual in-line stabilization without compromising the airway.
Consider Post-Paralysis:
- In some cases, optimal positioning is achieved after paralysis and induction to ensure proper relaxation of the muscles.

5. Preoxygenation

Maximize Oxygen Reserves:
- Preoxygenate the patient using a non-rebreather mask or BVM with 100% oxygen for 3-5 minutes to increase oxygen reserves and reduce the risk of hypoxia during the apneic period.
- In spontaneously breathing patients, consider passive oxygenation via nasal cannula in addition to preoxygenation.
Avoid Hyperventilation:
- Ensure proper ventilation rate and tidal volume, avoiding hyperventilation which can cause hypoventilation.

6. Pretreatment (Optional)

Medications for Specific Situations:
- Atropine: May be used in pediatric patients to prevent bradycardia during intubation, especially in those under the age of 1.
- Fentanyl: May be used in patients with increased intracranial pressure or cardiac conditions to blunt the sympathetic response.
- Lidocaine: May be administered to reduce the risk of increased intracranial pressure during intubation, though its use is less common.
Timing:
- Administer pretreatment drugs 3 minutes before induction to allow them to take effect.

7. Paralysis and Induction

Induction:
- Administer the induction agent (e.g., etomidate, ketamine) rapidly to induce unconsciousness, followed immediately by the paralytic agent.
Paralysis:
- Administer the neuromuscular blocking agent (e.g., succinylcholine or rocuronium) to achieve complete paralysis, facilitating intubation.
Sequence:
- The sequence is critical: induction agent first to prevent patient awareness, followed by the paralytic to facilitate intubation.

8. Placement with Proof

Intubation:
- Insert the endotracheal tube (ETT) with the help of a laryngoscope, ensuring the tube passes through the vocal cords and into the trachea.
Confirmation:
- Confirm ETT placement by visualizing the tube passing through the vocal cords, auscultating for bilateral breath sounds, and using capnography to verify end-tidal CO2.
- Look for chest rise, misting in the tube, and the absence of epigastric sounds to confirm proper placement.
Secure the Tube:
- Secure the ETT with a tube holder or tape to prevent dislodgement during transport.

9. Post-Intubation Management

Ongoing Sedation and Analgesia:
- Continue sedation and analgesia to keep the patient comfortable and prevent awareness during mechanical ventilation.
- Administer medications such as midazolam or propofol for sedation, and opioids like fentanyl for pain control.
Ventilation and Monitoring:
- Ensure proper ventilation settings on the mechanical ventilator or BVM, and continuously monitor oxygenation, ventilation, and hemodynamics.
- Regularly reassess ETT placement and patency, ensuring that the tube remains secured.
Management of Complications:
- Be prepared to manage any complications, such as hypotension due to sedatives, or difficulties with ventilation.

Conclusion

The 9 P’s of Rapid Sequence Intubation provide a comprehensive framework for EMS providers to manage critical airways effectively and safely. Understanding each step, from planning and preparation to post-intubation management, ensures that providers are prepared to handle the challenges of RSI in the field.

Continuous training, adherence to protocols, and effective teamwork are key to successful outcomes in airway management.

mark tozer's blog

Monday, August 05, 2024

EMS Airway Management - The 9 P’s of Rapid Sequence Intubation (RSI)