The Rapid Sequence Intubation is one of those “gotta have” skills for clinicians who work in frontline medicine. Fair to say there are a lot of sequences out there, but they all follow the same basic plan – prepare, inject the juice, and get the airway secured ASAP. In recent years there have been a few changes to the long-held anaesthetic dogma, based on good evidence. So I thought I would take a look at a few, see what is new in RSI.
In case you have been living under a rock and missed the Weingart & Levitan paper on Pre-oxygenation and Avoiding Desaturation in Emergency Airway Management here it is. The practice of throwing on a Hudson mask at 6 litres/min for 5 minutes is no longer the standard of pre-ox we should be aiming for. Weingart and Levitan have broken down the evidence and created a 3 tier risk-stratification of sick patients with incredibly practical strategies to optimise the pre-ox and decrease the rate of desaturation that inevitably occurs in the sick patients.
- NIV as pre-oxygenation device – minimise the shunt, maximise the alveolar recruitment
- Use of a viva-bag with a cheap PEEP vlave as a poor mans CPAP device
- USe of high flow (15l/min) nasla cannula oxygen to keep the flow of oxygen throughout the procedure and make your apnoeic time much safer for longer.
- Check out the tables on the last page of the above paper – it is pretty simple and self-explanatory
The role of cricoid pressure in emergency airway management has come under a lot of scrutiny in recent years. As is often the case when we look back at the original data – it seemed like a good idea, had some experimental data to support it – but there was no good large-scale evidence that it made a difference to the outcome which we and patients care about!
There was a good review published last month taht asked the hard questions – in Trends in Anaesthesia and Critical Care 2012, Priebe looked at the data in a systematic manner and tried to separate facts from fiction.
- Cricoid pressure does not have the evidence to make it a mandatory manouvre
- Clinicians should use individual judgement to guide its use
- It may be applied, and may help prevent gastric insufflation during BM ventilation
- If your glottic view is obscured / inadequate – remove it ASAP, then consider BURP instead
- There is a paucity of good, reliable evidence to support or deny the use of cricoid pressure!
There have been a few recent debates on the use of muscle relaxants.
- Should they be used at all in critical care settings? For me this was a surprise, as I was trained by anaesthesia docs who always used them, but there is a tendency to avoid them in some ICUs. If you want to hear the low-down on the debate in a very enertaining deabte go to Emcrit and listen to the Paralytics debate. Fair to say it has yet to be decided – but I think for the average GP-intubation it remains the standard to use a muscle relaxant.
- Which muscle relaxant? Roc vs. Sux? well there have been a few posts and opinions out there – check out my post from last year and links to other resources.
- In summary – Roc seems to prolong the time to desaturation
- Give it in a big dose ~ 1.2mg/kg and its onset is comparable to Sux
- The “back out” plan that Sux ‘allows’ usually is not an option in true critical / emergency RSI
- You don’y have to worry about the patient fighting the vent anytime soon if you use Roc!
Last point – The PPPPPPP rule [proper planning and preparation prevents piss poor performance]
Having a well thought-out team-orientated approach to emergency airways is the most important thing to do to make your RSIs go well. This should be done as part of your departments training / drills and education programme.
Dr Tim (KI Docs) has sent me this nifty little aide-memoir to help get your preparation right and to jog one’s thoughts with asimple checklist included. I will put it in the Resources section at the bottom of the blog, but click here to have a look at the RSI DUMP kit mat. Print it out in A# or bigger and put it on your resus room trolley. Thanks Tim
Let me know if this helps – or if you have other new pearls for the old RSI setup.