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Chapter 8 Rapid Sequence Intubation
- University of Ottawa Press
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C H A P T E R 8 RAPID SEQUENCE INTUBATION A 73-year-old male has come into your emergency room with an upper gastrointestinal bleed. He is pale and cool with vital signs ofHR 130, BP 85/40, RR 24 and SpO2 85%.He is vomiting bright red blood and is disoriented and uncooperative. Over the next few minutes, as you apply 100% O2 and begin to fluid resuscitate him, he progressively becomes more hypoxemic and obtunded and you areconcerned about ongoing aspiration. What doyou do? MICHELLE CHIU AND DAVE NEILIPOVITZ The patient in this scenario presents the physician with many conflicting problems: The patient is hemodynamically unstable and needs further fluid resuscitation. Thepatient, however, may aspirate and suffer adverse pulmonary consequences if his airway is not secured immediately. The high likelihood of impending aspiration drastically decreases the time available to adequately resuscitate him. Theurgency also reduces the time available to gently sedate and topicalize the airway, never mind the unlikelihood of being able to effectively topicalize his airway due to the ongoing hematemesis. The technique of rapid sequence intubation (RSI)has been advocated for a patient who requires endotracheal intubation but who is at high risk for aspiration of gastric contents. The goal of this chapter is to present the techniqueof RSI and discuss the advantages and disadvantagesof this approach to airway management. • Overview The primary goal of the RSItechnique is to provide optimal intubating conditions as quickly as possible. In brief, it involves pre-oxygenation of the patient, followed by rapid administration of predetermined doses of drugs and the application of cricoid pressure prior to intubation (Table 8.1). The logic underlying RSI is to minimize the duration of time between the patient's loss of consciousness and the inflation of the cuff of an endotracheal tube in the trachea. The 65 Table 8.1 - Overview of RSI 1. Preparation for Intubation 2. Pre-oxygenatron 3. Induction Drug Administration 4. Application of Cricoid Pressure 5. Paralyzing Drug Administration 6. Endotracheal Tube Insertion 7. Inflation of Cuff on Tube 8. Confirmation of Tube Placement 9. Release of Cricoid Pressure premise is that during the time when the patient is unconscious and airway reflexes are lost, the patient is at the highest risk for aspiration of gastric contents. In general, RSIis the preferred method for securing a patient's airway in emergency situations or when a patient is at a very high risk for regurgitation and aspiration.1 "3 The use of RSI is also recommended to secure the airway of a patient with increased intracranial pressure (ICP).4 RSIis preferred because disastrous elevations in the ICP associated with laryngoscopy are mitigated by the induction drugs, and the patient is unlikely to cough due to the paralyzing agents. Although the technique offers considerable advantages to airwaymanagement, the potential for disastrous and irreparable complications are inherent in its use. The exact origin of RSI is unclear but is most likely attributable to Morton and Wylie in 1951.5 The technique they described is very similar to the modern day method with the exception that cricoid pressure6 was not included.Mortonand Wylie stated that the technique provided for "a pleasant induction and facilitates quick and easy intubation/7 They recommended, however, that the use ofthis approach be restricted and that it should not be attempted by inexperienced physicians because of the greater likelihood ofcomplications associated with itsuse.The authors cautioned that it was only suitable for healthy patients as the rapid administration ofpredetermined doses ofthe induction drugs could causecatastrophic circulatory problems. Indeed, the inherent hazards of RSIwere reflected in the colloquial synonym that was often used to describe the method: "crash induction/' Numerous reports followed that described deaths that were attributed to this technique and suggested caution for its widespread use along with its potential limitations.7 '9 The use of RSI was primarily restricted to anesthesiologists until the 1980s. Prior to this time, emergency intubation in a spontaneously breathing patient by non-anesthesiologists was usually performed by awake nasotracheal intubation.10 The role of a modified RSI for emergency patients was periodically suggested but the method was restricted to experienced anesthesiologists.11 By the late 1980s and early 1990s, a shift from nasotracheal intubation to RSIfor emergency airway management by nonanesthesiologists had occurred.12 Thereasons for this are numerous but primarily rest on the fact that this technique has a higher success rate and potentially fewer complications compared to nasotracheal intubation.13 '14 Illustrative of this paradigm shift is...