Rapid Sequence Intubation Summary Questions

1. Which of the following statements about Rapid Sequence Intubation (RSI) is INCORRECT:

RSI minimizes the risk of pulmonary aspiration

RSI increases the chance of successful intubation by inducing paralysis

RSI minimizes untoward physiologic responses due to direct laryngoscopy

RSI is the method of choice to secure an airway for a patient in cardiopulmonary arrest

The indications for RSI are: inadequate ventilation, inadequate oxygenation, functional or anatomic airway obstruction, loss of protective airway reflexes (cough and/or gag), respiratory fatigue with impending respiratory failure, shock, severe multiple trauma, severe head injury, and sedation in combative patients to facilitate emergency evaluation and treatment. There is no need to perform the complete series of steps associated with RSI in patients who are in cardiac arrest or already deeply comatose who require immediate airway control. Relative contraindications to RSI include significant anatomic features indicating poor likelihood of successful endotracheal tube, major facial or laryngeal trauma, and suspected upper airway obstruction or epiglottitis in the awake and spontaneously breathing patient who is dependent on the muscle tone of the upper airway to maintain airway patency.

Explanation

The indications for RSI are: inadequate ventilation, inadequate oxygenation, functional or anatomic airway obstruction, loss of protective airway reflexes (cough and/or gag), respiratory fatigue with impending respiratory failure, shock, severe multiple trauma, severe head injury, and sedation in combative patients to facilitate emergency evaluation and treatment. There is no need to perform the complete series of steps associated with RSI in patients who are in cardiac arrest or already deeply comatose who require immediate airway control. Relative contraindications to RSI include significant anatomic features indicating poor likelihood of successful endotracheal tube, major facial or laryngeal trauma, and suspected upper airway obstruction or epiglottitis in the awake and spontaneously breathing patient who is dependent on the muscle tone of the upper airway to maintain airway patency.

2. A Trauma Stat is called for a 14 yo male who fell from a ladder with waxing and waning mental status and BP 90/40 with 10 minute ETA. You instruct your med nurse to draw up RSI meds. Your sedative of choice is Etomidate for all the following reasons EXCEPT:

It is readily available in the code room pyxis

It causes minimal cardiovascular depression

It will keep the patient sedated while getting the CT scan and transferred to the PICU

It decreases Intracranial pressure

Etomidate is the most commonly used sedative in both adult and pediatric Emergency departments. It is
o Ultrashort-acting and extremely reliable (Onset: 15-30 seconds)
o It’s duration of action is only 4-10 minutes so it is not likely to last long enough to get a patient through the CT scan and to the PICU.
o Causes minimal CV depression
o Decreases ICP
o Sedative of choice in a patient with multisystem trauma, hypotension, and/or head injury

Explanation

Etomidate is the most commonly used sedative in both adult and pediatric Emergency departments. It is
o Ultrashort-acting and extremely reliable (Onset: 15-30 seconds)
o It’s duration of action is only 4-10 minutes so it is not likely to last long enough to get a patient through the CT scan and to the PICU.
o Causes minimal CV depression
o Decreases ICP
o Sedative of choice in a patient with multisystem trauma, hypotension, and/or head injury

3. EMS calls with a 10minute ETA for a 2yo male shot to the chest by a stray bullet at a picnic now in respiratory distress. You call a Trauma Stat attending and give an estimated weight and instructions to have the following equipment ready:

Weight: 12kg; ETT 5.5mm; 11 Fr NG/OG; 18 Fr Chest tube

Weight: 16 kg; ETT 4.5mm; 8 Fr NG/OG; 16 Fr Chest tube

Weight: 12kg; ETT 4.5mm ; 9Fr NG/OG; 18 Fr Chest tube

Weight: 16 kg; ETT 4.5mm; 8 Fr NG/OG; 16 Fr Chest tube

Weight 14kg; ETT 4.0mm; 11 Fr NG/OG; 20 Fr Chest tube

The following are shortcuts to estimating weight, ETT size, Depth of ETT insertion, Foley NG/OG tube size and Chest tube size:

Weight (kg’s, 1-10 years): 8 + [age (yrs) x 2] ; 8+[2x2] = 12kg

ETT size (uncuffed) : [age (yrs)/4] + 4; (cuffed is 0.5mm smaller); [2/4] +4 = 4.5mm
Depth of ETT insertion (cm’s): 3 x ETT size; 3x4.5 = 13.5cm
Foley or NG/OG tube size: 2 x ETT size; 2 x 4.5 = 9Fr
Chest tube size: 4 x ETT size; 4x4.5 = 18
Note: Selecting appropriate equipment is fundamental to intubation success and patient safety. Also recall the appropriate blade size: “Size 2 blade at 2 years old.” Size 1 blades are appropriate for younger infants, and size 3 blades can be used starting at 10-12 years old.

Explanation

The following are shortcuts to estimating weight, ETT size, Depth of ETT insertion, Foley NG/OG tube size and Chest tube size:

Weight (kg’s, 1-10 years): 8 + [age (yrs) x 2] ; 8+[2x2] = 12kg

ETT size (uncuffed) : [age (yrs)/4] + 4; (cuffed is 0.5mm smaller); [2/4] +4 = 4.5mm
Depth of ETT insertion (cm’s): 3 x ETT size; 3x4.5 = 13.5cm
Foley or NG/OG tube size: 2 x ETT size; 2 x 4.5 = 9Fr
Chest tube size: 4 x ETT size; 4x4.5 = 18
Note: Selecting appropriate equipment is fundamental to intubation success and patient safety. Also recall the appropriate blade size: “Size 2 blade at 2 years old.” Size 1 blades are appropriate for younger infants, and size 3 blades can be used starting at 10-12 years old.

4. All of the following are indications for using Atropine as a premedication for RSI EXCEPT:

12 yo intoxicated patient with GCS 7

9 mo male with respiratory distress

2 yo trauma stat patient with closed head injury

15 yo male requiring a second dose of succinylcholine

Infants and children have a more pronounced vagal response to laryngoscopy and endotracheal intubation than adults. In addition, profound bradycardia and even asystole have been documented after succinylcholine administration. Atropine premedication will avoid these complications. Atropine also decreases oral secretions, making it easier to visual landmarks during intubation. Atropine is indicated for:
• Infants less than 1 year of age (Choice B)
• Children 1 to 5 years of age receiving succinylcholine (Choice C - Recall that our Trauma Stat protocol recommends Succinylcholine for RSI, hence this is assumed for this choice)
• Older children who require a second dose of succinylcholine because of a failed first intubation attempt (Choice D)
• Children receiving ketamine for sedation for RSI.

The dose of atropine is 0.02 mg/kg (minimum 0.1 mg, maximum 1 mg) IV given 1-2 minutes prior to intubation.

Explanation

Infants and children have a more pronounced vagal response to laryngoscopy and endotracheal intubation than adults. In addition, profound bradycardia and even asystole have been documented after succinylcholine administration. Atropine premedication will avoid these complications. Atropine also decreases oral secretions, making it easier to visual landmarks during intubation. Atropine is indicated for:
• Infants less than 1 year of age (Choice B)
• Children 1 to 5 years of age receiving succinylcholine (Choice C - Recall that our Trauma Stat protocol recommends Succinylcholine for RSI, hence this is assumed for this choice)
• Older children who require a second dose of succinylcholine because of a failed first intubation attempt (Choice D)
• Children receiving ketamine for sedation for RSI.

The dose of atropine is 0.02 mg/kg (minimum 0.1 mg, maximum 1 mg) IV given 1-2 minutes prior to intubation.

5. A 7yo ill appearing male with a history of renal failure and chronic lung disease presents with vomiting and altered mental status. He is tachycardic, and has deep respirations. His capillary refill is 4-5 seconds and BP of 70/20. Which of the following would be MOST CORRECT regarding your choice of paralytic agent for RSI?

Succinylcholine is best given its rapid onset, short duration of action and is most readily available in the ED pyxis

You may not want to consider Succinylcholine in this patient given the contraindications for use in patients with renal failure. Other contraindications include: rhabdomyolysis, extensive crush injuries, hyperkalemia, increased intracranial pressure, glaucoma, penetrating eye injuries, significant neuromuscular disease, extensive trauma or burns older than 48 hours, concern for malignant hyperthermia, pseudocholinesterase deficiency, myotonia, muscular dystrophy and paraplegia. Choice C is incorrect because of the phrase “readily available”. Vecuronium is often inconvenient because it comes in powder form and requires reconstitution. Choice D is inaccurate because pancuronium has a much slower onset than the other choices of 120-140 secs and would not be the best agent in this scenario. Choice B is the best choice.

Explanation

You may not want to consider Succinylcholine in this patient given the contraindications for use in patients with renal failure. Other contraindications include: rhabdomyolysis, extensive crush injuries, hyperkalemia, increased intracranial pressure, glaucoma, penetrating eye injuries, significant neuromuscular disease, extensive trauma or burns older than 48 hours, concern for malignant hyperthermia, pseudocholinesterase deficiency, myotonia, muscular dystrophy and paraplegia. Choice C is incorrect because of the phrase “readily available”. Vecuronium is often inconvenient because it comes in powder form and requires reconstitution. Choice D is inaccurate because pancuronium has a much slower onset than the other choices of 120-140 secs and would not be the best agent in this scenario. Choice B is the best choice.