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6 - Preparation for rapid sequence induction and tracheal intubation
- Edited by Jonathan Benger, Jerry Nolan, Mike Clancy
-
- Book:
- Emergency Airway Management
- Published online:
- 22 August 2009
- Print publication:
- 06 November 2008, pp 51-58
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- Chapter
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Summary
Objectives
The objectives of this chapter are to understand how to:
prepare thoroughly for rapid sequence induction (RSI) and tracheal intubation
position patients optimally to maximize the success of laryngoscopy and intubation
assemble and check the equipment and drugs required for RSI and tracheal intubation
use appropriate monitoring and know its strengths and limitations
reassess the patient rapidly and ascertain all the required information before undertaking RSI
identify and use team resources appropriately to maximize team co-operation and understanding.
Introduction
Making the decision that a patient requires a rapid sequence induction (RSI) is the entry point to the sequence of preparation for this procedure. While there may be times when intubation of the patient needs to be achieved immediately, there are very few instances in which placement of the tracheal tube is so time critical that these basic preparatory steps cannot be followed. With a systematic approach and good team working, this will take only a few minutes and avoid many possible problems and complications.
The PEACH approach (Box 6.1) provides a useful mnemonic.
Positioning
Correct positioning of the patient's head and neck improves the view of the larynx at laryngoscopy and the likelihood of successful intubation. Alignment of the oral, pharyngeal and laryngeal axes during laryngoscopy provides a clear view from the incisors to the laryngeal inlet (see Chapter 4).
Approximately 20% of RSI undertaken in the emergency department require stabilization of the cervical spine: in almost all other cases the patient should be placed in the optimum intubating position, unless spinal deformity or arthritis makes this impractical or inadvisable.
8 - Pharmacology of emergency airway drugs
- Edited by Jonathan Benger, Jerry Nolan, Mike Clancy
-
- Book:
- Emergency Airway Management
- Published online:
- 22 August 2009
- Print publication:
- 06 November 2008, pp 67-80
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- Chapter
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Summary
Objectives
The objectives of this chapter are to:
be familiar with the choice of induction, analgesic and neuromuscular blocking drugs
understand the advantages and disadvantages of drugs used in emergency airway management
understand the basic pharmacology of these drugs
be aware of the possible complications caused by these drugs.
Introduction
The term ‘triad of anaesthesia’ is used to describe the components of a balanced anaesthetic:
hypnosis
analgesia
muscle relaxation.
The pharmacology of drugs used commonly in emergency airway management will be considered under these three headings.
In unmodified rapid sequence induction (RSI) an analgesic is omitted and the patient is given a pre-calculated dose of induction drug and neuromuscular blocker only. The rationale behind this is that, should intubation fail, the patient will recover from anaesthesia and paralysis quickly, returning to spontaneous ventilation. Opioids, particularly in high doses, will increase the time to spontaneous ventilation. Some patients may have received analgesia before the induction of anaesthesia (e.g. for pain relief in trauma), and under some circumstances it is appropriate to consider modifying an RSI to include a carefully selected dose of opioid given before the induction drug (e.g. RSI in the presence of raised intracranial pressure: see Trauma and raised intracranial pressure in Chapter 11). Opioids are also useful after intubation, when they may be used in combination with a hypnotic to maintain anaesthesia and reduce sympathetic stimulation.
7 - Rapid sequence induction and tracheal intubation
- Edited by Jonathan Benger, Jerry Nolan, Mike Clancy
-
- Book:
- Emergency Airway Management
- Published online:
- 22 August 2009
- Print publication:
- 06 November 2008, pp 59-66
-
- Chapter
- Export citation
-
Summary
Objectives
The objectives of this chapter are to understand:
the importance of pre-oxygenation
the technique of rapid sequence induction (RSI) of anaesthesia and tracheal intubation
the confirmation of successful intubation
the importance of immediate review of patient physiology after intubation.
Introduction
Rapid sequence induction of anaesthesia (RSI) involves injecting an anaesthetic induction drug to achieve hypnosis, rapidly followed by a neuromuscular blocking drug to produce complete paralysis. To prevent inflation of the stomach, the lungs are not usually ventilated between induction and intubation, and the airway is protected by applying cricoid pressure to prevent regurgitation of gastric contents. The time from loss of consciousness to securing the airway is minimized because the patient's stomach is assumed to be full.
Pre-oxygenation
Effective pre-oxygenation replaces the nitrogen in the alveoli with oxygen, which increases the oxygen reserve in the lung. Pre-oxygenation maximizes the time before desaturation occurs following the onset of apnoea. This provides more time for intubation to be attempted before having to stop to re-oxygenate the patient's lungs (see Chapter 2). Whenever possible, give 100% oxygen for three minutes before induction of anaesthesia. A patient who is breathing inadequately may not achieve enough alveolar ventilation to replace nitrogen in the lungs with oxygen. These patients may therefore require assisted ventilation to achieve adequate pre-oxygenation before RSI.
The time to desaturation is related not only to the effectiveness of the pre-oxygenation phase, but also to the age and weight of the patient and their physiological status.