RAPID SEQUENCE INDUCTION
Rapid Sequence Induction (RSI) is an advanced medical procedure, designed for the expeditious intubation of the trachea of a patient. RSI is generally used for patients who have an increased risk of aspirating stomach contents into the lungs due to a current disease process.
Technique:
The technique, RSI, strictly refers to the sedation and paralysis prior to an intubation procedure. The technique is a quicker form of the process normally used to "induce" a state of general anesthesia. The difference between an RSI and standard anesthetic intubation is that the anesthetist does not wait to see the effect of the drugs. Medications are utilized to allow rapid placement of an endotracheal tube between the vocal cords, while the cords are being visualized with the help of a laryngoscope. The neuromuscular blocking agents paralyze all of the patient's skeletal muscles, most notably in the oropharynx , larynx, and diaphragm. Once the endotracheal tube has been passed between the vocal cords, a cuff is inflated around the tube in the trachea and the patient can then be artificially ventilated.
RSI involves pre-oxygenating the patient with a tightly-fitting oxygen mask, followed by the sequential administration of pre-determined doses of a hypnotic drug and a rapid-acting neuromuscular blocker. Hypnotics used include Thiopental, Propafol and Etomidate. Neuromuscular-blocking drugs used include Suxamethonium (sometimes with a defasciculating dose of Vecuronium) and Rocuronium.[1] Other drugs may be used in a "modified" RSI. When performing endotracheal intubation, there are several adjunct medications available. No adjunctive medications, when given for their respective indications, have been proven to improve outcomes.[2] Opioids such as Alfentanil or Fentanyl may be given to attenuate the responses to the intubation process (tachycardia and raised intracranial pressure). This is supposed to have advantages in patients with ischemic heart disease and those with intra-cerebral hemorrhage (e.g. after traumatic head injury or stroke). Lidocaine is also theorized to blunt a rise in intracranial pressure during laryngoscopy, although this remains controversial and its use varies greatly. Atropine may be used to prevent a reflex bradycardia from vagal stimulation during laryngoscopy, especially in young children and infants.
Requirement:
The clinician that performs RSI must be skilled in intubation. Failure to intubate means needing to ventilate by mask. The clinician that performs RSI must be knowledgeable about the drug administered. The clinician must understand the time to onset of action of a drug and the required dosage. Otherwise, the clinician risks paralyzing a fully conscious patient. The clinician must also be aware of possible side effects of the drugs such as malignant hyperthermia. The clinician must use sound judgment in selecting which drug is to be used and the amount to be used.
Meticulous preparation and planning is necessary. Back-up plans must be in place. Plans may include the option to move to a non-visualized airway such as the Combitube, or laryngeal mask airway. A mandatory emergency back-up plan is an emergency cricothyrotomy.
This procedure is extremely dangerous. A clinician removes all ability of the patient to breathe or to maintain a patent airway. For this purpose, most pre-hospital paramedic ambulances are required to have two paramedics in the patient compartment when performing this procedure.
Conclusion:
This procedure is usually performed by an anesthesia provider (e.g., physician anesthesiologist, certified registered nurse anesthetist, anesthesiologist assistant (AA-C)) in surgery and by medical personnel in the emergency department. It may also be performed in the prehospital setting [1] by persons trained to the paramedic level, including flight medics and flight nurses.
References:
1. ^a b Rapid Sequence intubation for Pre-hospital Providers
2. ^ David T. Neilipovitz, Edward T. Crosby: No evidence for decreased incidence of aspiration after rapid sequence intubation, in: Canadian Journal of Anesthesia 54,9,2007, S. 748-764 Abstract,
Rapid Sequence Case Studies A Case Study Involving Rapid Sequence Induction Conducted by our own Dr. Sing and some of his colleagues.
Am J Emerg Med. 1998 Oct;16(6):598-602.
Rapid sequence induction for intubation by an aeromedical transport team: a critical analysis.
Sing RF, Rotondo MF, Zonies DH, Schwab CW, Kauder DR, Ross SE, Brathwaite CC.
Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA. Airway control is the initial priority in the management of the injured patient. The purpose of this investigation was to evaluate the experience of an aeromedical transport team in the utilization of rapid sequence induction (RSI) for endotracheal intubation in the prehospital setting. Records of a consecutive series of injured patients undergoing RSI between June 1988 and July 1992 by a university-based aeromedical transport team were reviewed for demographics, intubation mishaps, and pulmonary complications. The relationship between intubation mishaps and pulmonary complications was analyzed. Eighty-four patients were studied with a mean age of 30.8 +/- 15.3 years. The mean Revised Trauma Score was 11.3 +/- 2.4, and the mean Injury Severity Score (ISS) was 19.6 +/- 11.5. Intubation mishaps occurred in 15 patients (18%), and pulmonary complications developed in 22 (29%) of the 75 patients surviving longer than 24 hours. There was no relationship between intubation mishaps and pulmonary complications. Abbreviated Injury Scale (AIS) face score was significantly higher in patients with intubation mishaps, compared with patients without mishaps (1.1 +/- 1.2 and 0.5 +/- 0.9, respectively, P < .05, Wilcoxon rank-sum). ISS and AIS chest were higher in patients with pulmonary complications, compared with those without (25.7 +/- 12.6 and 17.4 +/- 10.3 and 2.2 +/- 1.8 and 1.0 +/- 1.5, ISS and AIS respectively; P < .05, Wilcoxon rank-sum). Eighty-one patients (96%) underwent successful RSI, 73 (87%) on the first attempt. Failure to intubate occurred in three patients (4%). Performed under strict protocol by appropriately trained aeromedical transport personnel, RSI is an effective means to facilitate endotracheal intubation in the injured patient requiring definitive airway control. Pulmonary complications were related to injury severity and not to intubation mishaps. PMID: 9786546 [PubMed - indexed for MEDLINE]
Rapid Sequence Induction
