-
Preoxygenate
- Variety of techniques...
- at minimum NC @ 15 to 25 lpm and NRM
- If this is inadequate or pt remains hypoxic NONINVASIVE POSITIVE PRESSURE VENTILATION (NIPPV) CPAP or BIPAP
-
Push
- Push an appropriate SEDATIVE
- A. ETOMIDATE (0.3-0.4mg/kg IV/IO)
- B. KETAMINE (1-2mg/kg IV/IO) - in place of or in addition to ETOMIDATE in bronchospastic patient OR substiture to ETOMIDATE where hypotension exists
-
Paralyze
- SUCCINYLCHOLINE 2mg/kg
- VECURONIUM 0.1mg/kg
- ROCURONIUM 1mg/kg
-
Placement with proof
- Place endotracheal tube and verify placement!
- 1. Note passage through the vocal cords/glottic opening
- 2. Absence of gastric sounds
- 3. Presence of bilateral lung sounds and wave form capnography with 1st breath
- - if an incomplete view of the glottis or no view then external laryngeal manipulation
- - bougi should be considered for patrial or minimal views (Cormack-Lehane grades 3/4)
-
Protect and Position
- * Sellick's maneuver may be applied to guard against aspiration
- * Position into a "sniffing" position or align the auditory meatus with the sternum
-
Post Intubation Managment
- S E C U R E T U B E
- SEDATION
- versed 0.05 to 0.1 mg/kg 5mg MAX Q5min
- ativan 0.05 to 0.1 mg/kg
- PAIN MGT
- fentanyl 0.5 to 1 mcg/kg 100 mcg MAX Q5min (300mcg/kg)
- morphine 0.5 to 0.1 mg/kg 10 mg MAX Q10min (20mg MAX)
- ketamine 0.5 mg/kg 50mg MAX Q 15min
- PARALYSIS
- vecuronium 0.1 mg/kg 10mg MAX
- rocuronium 1 mg/kg 100mg MAX
- PUSH DOSE PRESSORS
- epi 5 to 20 mcg
- phenylphrine 100mcg
-
RSI EIGHT Ps
- 1. PREPARE
- 2. PREOXYGENATE
- 3. PRETREATMENT
- 4. PUSH
- 5. PARALYZE
- 6. PROTECT AND POSITION
- 7. PLACEMENT WITH PROOF
- 8. POST INTUBATION MANAGEMENT
-
MOANS
- (difficult to bag?)
- MASK - seal difficult
- OBESITY/OBSTRUCTION
- AGE > 55
- NO TEETH
- STIFF LUNGS OR CHEST WALL
-
RODS
- (difficult extraglottic device)
- RESTRICTED MOUTH OPENING
- OBSTRUCTION (organic or foreign body)
- DISRUPTED/DISTORTED AIRWAY
- STIFF LUNGS OR SPINE
-
SHORT
- (difficult cricothyrotomy)
- SURGERY IN PAST (SCAR)
- HEMATOMA OR EXPANDING INFECTION
- OBESITY
- RADIATION THERAPY
- TUMOR
-
LEMONS
- LOOK EXTERNALLY (beard, bullneck, large tongue)
- EVALUATE 3-3-2
- MALLANPATI
- OBSTRUCTION (organic or foreign body)
- NECK MOBILITY (c-collar, disease process, injury, ect)
- SCENE, SPACE, SKILL
-
PREPARE
- 1. suction (hooked up and turned on)
- 2. intubating equipment
- 3. oxygen
- 4. multiple sized tubes
- 5. EGDs
- 6. medications
- 7. monitoring equipment
- 8. confirmation equipment
- (bvm w/ EtCO2 attached, commercial tube holder behind head)
-
PRETREATMENT
- You are NOT going to do this in MedCom exam!
- A. defasiculating paralytic - to limit fasciculation - from sucs/post procedure discomfort - vec or roc @ 10% dose
- B. lidocaine 1mg/kg 5 min prior to pre-intubation sedation
- C. atropine for PEDs - 0.02 mg/kg (mind dose 0.1mg)
- D. fentanyl - enhance sedative effect and possibly prevent increase in ICP during intubatioin
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