Rapid Sequence Induction Flashcards
What is the most commonly utilised strategy to aid the placement of an ET tube?
Rapid sequence induction (RSI)
Why use RSI?
It minimises the time between loss of airway reflexes and placement of ETT in the trachea. It minimises the risk of aspiration in patients who are inadequately starved, have impaired gastric emptying or gastric reflux
What are the indications for RSI?
A - airway protection and patency
B - respiration failure
C - minimise oxygen consumption and optimise oxygen delivery
D - low GCS, non terminating seizures, prevention of secondary brain injury
E - temperature control
F - humanitarian reasons, predicted clinical course, patient safety
What are the main drugs used in RSI?
Fentanyl - induction/pre med
Ketamine - induction
Rocuronium - paralytic
What is the dose, onset, duration, use and dangers of Fentanyl?
Dose: 2-10 mcg/kg
Onset: less than 60 secs
Duration: dose dependant
Use: low dose as a sympatholytic premed or modified RSI in low or titration doses on cardiogenic shock or other haemodynamic abnormalities
Danger: resp depression, apnoea, hypotension, nausea and vomiting, bradycardia
What is the dose, onset, duration, use and dangers of ketamine?
Dose: 1.5mg/kg
Onset: 60-90 secs
Duration: 10-20 mins
Use: any RSI, especially in haemodynamic instability or bronchospasm
Danger: increased secretions, hypertension, tachycardia, largngospasm
What is the dose, onset, duration, use and dangers of rocuronium?
Dose: 1.2 mg/kg
Onset: 60 secs
Use: used in any RSI, reversal is sugammadex
Danger: allergy (rare)
What is the 3,2,1 formula?
Refers to doses of fentanyl (3mcg/kg), ketamine (2mg/kg) and rocuronium (1mg/kg) developed by anaesthetist in trauma
Can the 3,2,1 formula be adapted?
Yes, it can be adapted to suit individual patients and in gross haemodynamic instability. A ratio of 1,1,1 can be used of drugs removed completely, normally fentanyl first
What are the steps of an RSI?
- Have a plan on the event of failure
- Suction needs to be available and working
- Preoxygenate
- Apply cricoid pressure
- Administer induction drug or sedation
- Administer muscle relaxant
- Intubate patient
- Inflate the cuff and confirm placement by auscultating chest and ensuring presence of end tidal CO2
- Release cricoid pressure
- Ventilate
When should a surgical airway be considered?
When an obstruction of the airway means that an ETT cannot be placed down the trachea to provide adequate oxygenation
What is the preferable surgical airway?
Surgical crycothyroidotomy
What does a needle cricothyroidotomy involve?
The insertion of a needle through the cricothyroid membrane into the trachea below the level of the obstruction to provide temporary, supplemental oxygenation on a short term basis until a definitive airway can be placed. Connect to oxygen at 15 L/min with a Y connector or a side hole in some O2 tubing with intermittent insufflation. Can adequately oxygenate for 30-45 mins
With the jet insufflation technique, what large-calibre cannula should be used in adults and children?
12-14 gauge for adults and 16-18 gauge for children
How is a surgical cricothyroidotomy performed?
Making an incision that extends through the cricothyroid membrane. A bougie is then inserted into the trachea and a small ETT over the bougie
