04.01 Rapid Sequence Intubation

RSI is a cornerstone of emergency airway management. It is a skill that every ED doc has and uses. As nurses, we need to know some very specific things. What are the indications? Who needs to be in the room, who actually helps with the procedure? What do we need, like equipment, medication, that kind of stuff? What do we need once the tube is in place? And what is our role as nurses in the whole process?

First thing we need to know is when we use this. Well, just like any intubation, it is use for airway protection and whether you do it fast or slow, protecting the airway is the end result. We see it for respiratory failure, if a patient's respirations are slowing or getting to the point where they will no longer be breathing on their own, we will step in with RSI. Those who are going into shock and can't protect. Patients with intracranial hypertension, also can't protect the airway and as they deteriorate, the insertion of the ET tube can help to reduce some of the pressure by reducing the work of breathing. We also want to make it easier for patients in severe acute respiratory distress like our asthmatics or our COPDers.

As with any procedure in the ED, you need people. Not too many mind you, but enough to get the job done. You are going to need an ED Doc. This can be an attending, resident, fellow, whatever. In many of the facilities i have worked in, the doc is the one passing the tube. You also need some nurses. One is good, 2 is better. One will be assisting the doc directly and the other can draw up medications. You probably want a respiratory tech there to set up the ventilator (and in fact in some facilities, the respiratory tech is the one who passes the tube. And of course it never hurts to have some PCA’s on hand to gather equipment, get vitals, or do other simple tasks. I use the term PCA, but they have many names, basically nurses aides.

In order to do this, we need some equipment. Once we have ventilated the patient with a bag valve mask and their oxygen level is adequate, we need a laryngoscope to open the airway and help to visualize the vocal cords. Sometimes the docs will use a glidescope like this one which is basically just a laryngoscope with a camera on the end attached to a monitor. You obviously need the endotracheal tube. Please make sure the stylet, the rigid bendable tube that slides into the ET tube, is in place. Without this, the tube can become almost too flexible to insert. The stylet adds some rigidity to the tube and makes it easier to pass. You will also have a colorimetric capnometer on hand to attach once the tube is in place. This little device changes color from purple to yellow to confirm the presence of carbon dioxide and help to verify placement of the tube.

Once you have all your equipment in place, you want to make sure you have the right medications. Some protocols call for sedation prior to induction. Meds like medazolam or fentanyl are common. Once sedation is on board, or as a starting point you want to provide an anesthetic to basically knock the patient out. The one i am most used to is etomidate but you can use ketamine or propofol. And once the patient is “down” you now want to paralyze them to allow for passage of the ET tube. My favorite here is succinylcholine, or as it's commonly referred to, SUX. Other common meds here are rocuronium and vecuronium or Rock and Vec.