Endotracheal intubation using rapid sequence intubation (RSI) is the cornerstone of emergency airway management.
- Who needs to be there?
- What do we need?
- What do we need after?
- What is the nurses role?
- Airway protection
- Respiratory failure
- Intracranial Hypertension
- Reduce the work of breathing
- Who needs to be there?
- Physician (ED) or 2 or 3
- Nurse, or 2 or 3
- Respiratory Tech
- What do we need?
- What do we need after?
- Safety equipment
- The Nurses Role
- Drawing the drugs
- What can we push
- Bagging the Pt
- Verification of placement
- Monitoring Sats
- Ordering CXR
- If the patient is conscious, explain to them what is going to happen.
Hello everyone and welcome to today’s lesson on Rapid Sequence Intubation
RSI is a staple in the ED. You will see this almost every day in every trauma center in the country. It is a complicated process that is broken down into very specific steps and if you know what is happening and what comes next, you will be able to properly assist the physician with the procedure and make the process that much easier.
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.
Once the tube is in place, there are a few things we need to do. We want to make sure the patient remains sedated and doesn’t fight the tube. The common infusion here is propofol but there are other meds you can use for sedation like lorazepam.
We also need some extra equipment here. You want to get a tube securing device, this can be simple ET tube tape which wraps around the head and secures the tube or an actual ET tube holder which has a clamp that sits over the mouth and holds the tube in place. You also want to make sure you have a working ventilator at the bedside to attach the tube to. Bagging can get tiring after a while. Depending on the patients level of sedation you might want to consider wrist restraints here to prevent them from pulling at the tube. Of course, check with your facilities protocols on this one.
So the big question, what to we do here. Well when we decide to tube a patient, we need to get those meds, the process cant go anywhere if the patient is awake and alert. In terms of what we can push, most states allow nurses to push medications like Etomidate and sux but frown on pushing propofol. You guys all really need to check with your state and your facility on what you can push and what you can’t. As the doc is getting his equipment ready, we can be ventilating the patient with a bag valve mask. As he visualizes the cords with the laryngoscope, be there with the ET tube in hand to pass to him. Once they visualize the cords, they don’t like to look away so many will just reach out a hand for you to place the tube into. Once the tube is inplace, we need to verify. Attach the capnometer, listen for breath sounds, and make sure we have put in for that chest x-ray. During the entire process it is our job to keep an eye on those vital signs, especially the O2 sat. As they work to visualize the cords, and the patient is not receiving O2, you will see the sat drop. Let the ndoc know when its getting low..like below 90%. They might have to stop and ventilate the patient to bring the sat back up again. And once everything is in place and confirmed, we need to monitor the patient and titrate the sedation as necessary.
So it’s no secret that we perform RSI to maintain adequate oxygenation. Make sure we are watching that oxygen level. You have to know your meds. It can be really bad if we hand the doc the wrong thing and wind up paralyzing them before sedating them. And with any ED tasks, prioritization is key. Yes we want to get them intubated, but make sure we have a good O2 sat before we do.
A few key points. We want to know why we are intubating and how we need to do it. Make sure you have all the right equipment before we start. Know your medications and please do not mix them up. We have to monitor throughout the process and that continues to after they are intubated along with keeping an eye on their sedation level. You don’t want them to wake up and pull that tube out themselves….i have seen it happen.
Thank you for joining us on this quick overview of RSI. Please check out all our other emergency medicine lessons here on NRSNG.com and as always, HAPPY NURSING!!!