How fast does an RSI have to be? We see it called rapid-sequence intubation or rapid-sequence induction. Does this imply we should be rushing, moving too fast, and not being systematic or methodical? Are we creating an environment that causes us to be hurried, not optimizing opportunities for first-pass success, and creating the possibility for a hypoxic event or secondary insult?
Airway management is not just about sinking the endotracheal tube down a hole. It encompasses multiple body systems that collaborate with one another. Knowing the “why” to our treatments is critical.
I propose a new term: resuscitative intubation procedure, or RIP. This brings resuscitative to the forefront.
Resuscitation is a team sport and requires a well-organized approach. Let’s review the three top reasons why we miss our first intubation attempts:
Inadequate preparation (we didn’t set up our equipment, didn’t preoxygenate, the patient remains hypotensive, or we used poor drug choices);
Adequate preparation, but the attempt takes an extended time due to difficulty identifying landmarks and utilizing poor technique. In these situations we deplete our patient’s oxygen reserve;
One serious complication from poor airway management is hypoxia leading to cardiac arrest. A systematic approach can help prevent complications.
The HEAVEN criteria provide a novel difficult-airway prediction tool.
H = Hypoxemia—Good BLS airway maneuvers are key. We tend to forget how important airway adjuncts are. If patients can take one NPA, they can take two. If they can take an OPA, they can take an NPA. Using these adjuncts helps provide more flow when we ventilate. Don’t forget about patient positioning!
E = Extremes of size—Does the patient need to be ramped? Elevate the head of the bed so gravity doesn't work against you. Which equipment do you use, video or direct? What blade choice?
A = Anatomic disruption/obstruction—What do you notice from your assessment? Has there been blunt or penetrating trauma? Previous intubations or surgeries with scar tissue? Radiation or tumors? Have a plan to mitigate these factors prior to pushing induction agents or paralytics.
V = Vomit/blood/fluid—Employ SALAD (suction-aided laryngoscopy and decontamination). Have the right equipment on hand (such as a DuCanto suction catheter) and make sure it functions appropriately prior to use.
E = Exsanguination—Do we need to control bleeding? Fluid-resuscitate? Increase blood pressure before giving medications that take away compensatory measures? Literature suggests the combination of a low EtCO2 (less than 24 mmHg) and systolic BP of less than 80 mmHg means CPR will be needed within eight minutes.
N = Neck mobility—Do you need to keep c-spine in line, or is there room for manipulation? Will being inline restrict your view, requiring a modified technique?
Along with the HEAVEN criteria, an RSI checklist was developed to help providers embrace a comprehensive approach. Here are the steps of the RSI checklist.
Have your monitoring equipment in place. Using yours gives you the advantage of knowing your equipment, where to look for your numbers/waveforms, and how to mitigate any issues.
Consider fluid/blood/tension pneumothorax. What is your patient’s hemodynamic status, and could they benefit from fluid or blood resuscitation? What is their blood pressure or MAP? Will induction agents and paralytics cause hypotension and a negative outcome? If they have a pneumothorax, take care of that now to improve overall oxygenation.
NRB and passive oxygenation, more than 10 lpm. Estimate where your patient is on the oxyhemoglobin disassociation curve and work to increase their reserve.
Raise head of bed 30–35 degrees.
SpO2 less than 93%. BVM with two-thumbs-up technique, PEEP and EtCO2 on BVM mask. Two thumbs up gives a better seal with good manipulation while lifting the mandible without hand fatigue. Our physiologic PEEP is 3–5 cm H2O. Ventilating without PEEP does not leave alveoli open and doesn't assist oxygenation. Having the EtCO2 adapter applied to the BVM mask helps trend where the patient is and can assist after intubation.
Open c-collar if present.
Any HEAVEN difficult intubation indicators?
Suction on, operational and accessible. The standard Yankauer will not have sufficient power. Plan for the worst. The DuCanto's diameter allows for quick and sufficient flow.
Video laryngoscope on and warmed up. Know your equipment. How long does the camera stay on before it times out? Can the camera fog up and obscure your view?
Induction agent and paralytics drawn, and doses confirmed. What are your choices and why? What is their mechanism of action? How long do they last? Any side effects? Will they affect hemodynamic status? If you push them too fast, what response do they elicit?
ETT, bougie and alternative airway out and accessible. Choose a couple of different-size endotracheal tubes, as you may be surprised what you encounter when you get into the airway.
Induction agent administered. Remember the “why” to your choice, how it works, and your intended effects.
Paralytic agent administered. Remember the “why” to your choice, how it works, and your intended effects.
Suction prior to intubation attempt. Clear it out for the best view.
Intubate. Confirm placement, use direct visualization and EtCO2, and listen for breath sounds and epigastric sounds. Is the tube secure and an OG placed? Consider postintubation sedation.
Once the tube is in place, our job isn't over. Intubation can be traumatic. Keeping the patient comfortable will also assist us in oxygenation and ventilation.
Changing from RSI to RIP promotes a systematic approach. It can be delivered in a timely fashion with practice. Knowing the when, how, and why is critical.
Jennifer Noce, CCEMTP, FP-C, CCP-C, is Northeast regional clinical education manager for LifeNet of New York/Guthrie Air, Hagerstown, Md.