Mark Tozer, PhD: Documentation

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Monday, August 05, 2024

EMS Airway Management - The 9 P’s of Rapid Sequence Intubation (RSI)

The 9 P’s of Rapid Sequence Intubation (RSI) is a systematic approach that EMS providers use to ensure the safe and effective management of airway control in critically ill or injured patients.

Here's what EMS providers need to know about each step:

1. Plan

Strategic Planning:
- Assess the need for intubation based on the patient's condition, such as respiratory failure, decreased level of consciousness, or impending airway compromise.
- Consider alternative airway management strategies in case RSI fails (e.g., supraglottic airway, surgical airway).
Backup Plan:
- Establish a clear plan for what to do if initial attempts at intubation fail, including calling for additional help or preparing for an alternative airway.

2. Preparation

Drugs:
- Prepare and draw up all necessary medications for induction (e.g., etomidate, ketamine) and paralysis (e.g., succinylcholine, rocuronium).
- Check drug dosages based on the patient’s weight and condition, and label syringes clearly.
Equipment:
- Ensure all airway equipment is ready, including laryngoscope blades, endotracheal tubes (ETTs) of various sizes, stylets, and backup devices like the iGel.
- Check the functionality of suction devices, bag-valve masks (BVMs), and capnography monitors.
People:
- Assign roles to team members, ensuring clear communication about who will administer medications, who will perform the intubation, and who will monitor the patient.
- Designate someone to manage the patient’s cervical spine if trauma is suspected.
Place:
- Prepare the environment by ensuring adequate space, lighting, and a stable surface for the procedure.
- Ensure that all necessary equipment and personnel are within reach.

3. Protect the Cervical Spine

Cervical Spine Precautions:
- If trauma is suspected, manually stabilize the cervical spine to prevent movement and further injury.
- Consider in-line stabilization while maintaining the cervical collar and minimizing neck movement during intubation.

4. Positioning

Optimal Positioning:
- Position the patient in the “sniffing” position, with the head slightly elevated and the neck extended, to align the oral, pharyngeal, and laryngeal axes for better visualization during intubation.
- In patients with suspected cervical spine injuries, maintain manual in-line stabilization without compromising the airway.
Consider Post-Paralysis:
- In some cases, optimal positioning is achieved after paralysis and induction to ensure proper relaxation of the muscles.

5. Preoxygenation

Maximize Oxygen Reserves:
- Preoxygenate the patient using a non-rebreather mask or BVM with 100% oxygen for 3-5 minutes to increase oxygen reserves and reduce the risk of hypoxia during the apneic period.
- In spontaneously breathing patients, consider passive oxygenation via nasal cannula in addition to preoxygenation.
Avoid Hyperventilation:
- Ensure proper ventilation rate and tidal volume, avoiding hyperventilation which can cause hypoventilation.

6. Pretreatment (Optional)

Medications for Specific Situations:
- Atropine: May be used in pediatric patients to prevent bradycardia during intubation, especially in those under the age of 1.
- Fentanyl: May be used in patients with increased intracranial pressure or cardiac conditions to blunt the sympathetic response.
- Lidocaine: May be administered to reduce the risk of increased intracranial pressure during intubation, though its use is less common.
Timing:
- Administer pretreatment drugs 3 minutes before induction to allow them to take effect.

7. Paralysis and Induction

Induction:
- Administer the induction agent (e.g., etomidate, ketamine) rapidly to induce unconsciousness, followed immediately by the paralytic agent.
Paralysis:
- Administer the neuromuscular blocking agent (e.g., succinylcholine or rocuronium) to achieve complete paralysis, facilitating intubation.
Sequence:
- The sequence is critical: induction agent first to prevent patient awareness, followed by the paralytic to facilitate intubation.

8. Placement with Proof

Intubation:
- Insert the endotracheal tube (ETT) with the help of a laryngoscope, ensuring the tube passes through the vocal cords and into the trachea.
Confirmation:
- Confirm ETT placement by visualizing the tube passing through the vocal cords, auscultating for bilateral breath sounds, and using capnography to verify end-tidal CO2.
- Look for chest rise, misting in the tube, and the absence of epigastric sounds to confirm proper placement.
Secure the Tube:
- Secure the ETT with a tube holder or tape to prevent dislodgement during transport.

9. Post-Intubation Management

Ongoing Sedation and Analgesia:
- Continue sedation and analgesia to keep the patient comfortable and prevent awareness during mechanical ventilation.
- Administer medications such as midazolam or propofol for sedation, and opioids like fentanyl for pain control.
Ventilation and Monitoring:
- Ensure proper ventilation settings on the mechanical ventilator or BVM, and continuously monitor oxygenation, ventilation, and hemodynamics.
- Regularly reassess ETT placement and patency, ensuring that the tube remains secured.
Management of Complications:
- Be prepared to manage any complications, such as hypotension due to sedatives, or difficulties with ventilation.

Conclusion

The 9 P’s of Rapid Sequence Intubation provide a comprehensive framework for EMS providers to manage critical airways effectively and safely. Understanding each step, from planning and preparation to post-intubation management, ensures that providers are prepared to handle the challenges of RSI in the field.

Continuous training, adherence to protocols, and effective teamwork are key to successful outcomes in airway management.

Thursday, August 01, 2024

EMS Airway Management - iGel Supraglottic Airway Device

The iGel supraglottic airway device is an essential tool for EMS providers when managing a patient's airway, especially in situations where endotracheal intubation may be difficult or not immediately feasible.

Here’s some thing EMS providers need to know about the iGel:

1. Indications and Contraindications

- Indications: Emergency airway management in unconscious patients with absent or inadequate respiratory effort.

Alternative to endotracheal intubation during cardiac arrest, respiratory arrest, or when intubation is not possible.
Can be used in prehospital settings in combination with anesthesia, sedation, or other airway management situations requiring a secure airway.

- Contraindications:Conscious or semi-conscious patients with intact gag reflex.

Patients with known esophageal disease or pathology, such as esophageal varices.
Patients with a high risk of aspiration or who have ingested a large meal recently.
Severe airway trauma or obstruction that may prevent insertion.

2. Device Design and Features

Supraglottic Airway: The iGel is designed to sit above the glottis, creating a seal around the laryngeal inlet without inflating a cuff.
Gel-Like Cuff: The cuff is made of a soft, gel-like material that molds to the patient’s anatomy, minimizing trauma and reducing the need for precise sizing.
Integral Bite Block: Built-in bite block helps prevent the patient from biting down and occluding the airway.
Gastric Channel: The device includes a gastric channel that allows for the insertion of a gastric tube to decompress the stomach and reduce the risk of aspiration.
Sizing: The iGel comes in multiple sizes, typically based on patient weight, ranging from neonates to large adults.

3. Preparation and Insertion

Sizing: Select the appropriate size based on the patient’s weight.
Typical Ranges:

Size 1: Neonates (2-5 kg)
Size 2: Pediatric (10-25 kg)
Size 3: Small adult (30-60 kg)
Size 4: Medium adult (50-90 kg)
Size 5: Large adult (90+ kg)

Lubrication:Cover the back, sides, and cuff of the device with a water-based lubricant.

Avoid over-lubricating the front of the device to prevent blocking the airway opening.

Insertion Technique: Position the patient’s head in a neutral or slightly extended position.

Open the patient’s mouth and gently insert the iGel along the natural curve of the airway until resistance is felt, indicating it is seated correctly.
Avoid excessive force during insertion to prevent trauma.

Confirmation: Confirm placement by observing chest rise, listening for bilateral breath sounds, and using capnography (if available).
Security: Secure the device with a strap or tape to prevent dislodgement.

4. Maintenance and Monitoring

Ongoing Assessment: Continuously monitor for effective ventilation, chest rise, and oxygen saturation.

Regularly check for signs of dislodgement, obstruction, or leakage.

Gastric Decompression: If necessary, insert a gastric tube through the gastric channel to decompress the stomach and reduce the risk of regurgitation and aspiration.
Ventilation: Connect the device to a bag-valve mask (BVM) or ventilator, ensuring adequate tidal volume and oxygen delivery.

5. Complications and Troubleshooting

Airway Obstruction: If ventilation is inadequate, reassess the device placement, and consider repositioning or reinsertion.
Aspiration Risk: Despite the gastric channel, there is still a potential risk of aspiration; be prepared to manage this complication if it occurs.
Device Dislodgement: Regularly check the device's position and secure it properly to avoid dislodgement, especially during patient movement or transport.
Trauma or Discomfort: Monitor for signs of airway trauma or discomfort, particularly if insertion was difficult.

6. Removal

Timing: The iGel should be removed once the patient regains consciousness and airway reflexes, or if endotracheal intubation is indicated.
Technique: Gently withdraw the device while monitoring for any signs of obstruction, aspiration, or respiratory distress.

Prepare to manage the airway immediately if complications arise during removal.

7. Training and Proficiency

Simulation Training: Regular practice with the iGel device in simulated scenarios to maintain proficiency in its use.
Familiarization: EMS providers should be familiar with the different sizes and specific features of the iGel, including the gastric channel and the appropriate insertion technique.
Continuing Education: Stay updated on best practices, new developments, and guidelines related to supraglottic airway management.

8. Legal and Ethical Considerations

Scope of Practice: Ensure the use of the iGel is within the provider’s scope of practice as defined by their certification level and local protocols.
Informed Consent: While typically used in emergencies where consent cannot be obtained, providers should be aware of the ethical considerations in airway management.
Documentation: Document the size of the device used, time of insertion, confirmation methods, patient response, and any complications encountered.

Conclusion

The iGel supraglottic airway device is a valuable tool in the EMS provider’s airway management arsenal. Proper selection, insertion, and management are crucial to ensure effective ventilation and patient safety.

It was invented by Dr. Muhammed Aslam Nasir and is manufactured by Intersurgical.

Continuous training and familiarity with the device will enhance the provider's ability to use the iGel effectively in emergency situations.

Tuesday, July 30, 2024

EMS Airway Management - RSI v DSI

EMS providers should understand the key differences between Delayed Sequence Intubation (DSI) and Rapid Sequence Intubation (RSI) to determine the most appropriate approach for managing a patient's airway in critical situations.

Here are some things to know:

1. PURPOSE AND INDICATIONS

Rapid Sequence Intubation (RSI):

Purpose:

RSI is designed to secure the airway quickly and efficiently by inducing unconsciousness and paralysis in a matter of seconds, allowing for immediate intubation.

Indications:

RSI is used in situations where a patient requires immediate airway control, such as in cases of severe respiratory failure, trauma, or cardiac arrest, and where the patient is unable or unlikely to tolerate laryngoscopy without pharmacologic assistance.

Delayed Sequence Intubation (DSI):

Purpose:

DSI is a modified version of RSI that allows for the controlled induction of unconsciousness in a patient who needs preoxygenation but is either combative, anxious, or unable to tolerate preoxygenation.
The key difference is that DSI provides a window for preoxygenation after sedation but before paralysis.

Indications:

DSI is particularly useful in patients with conditions like severe hypoxia, agitation, or anxiety, where cooperative preoxygenation is necessary but not possible without sedation.
It’s often employed in cases where hypoxemia needs to be optimized before intubation.

2. SEQUENCE OF STEPS

RSI Steps:

Preoxygenation: The patient is preoxygenated, typically with a non-rebreather mask or BVM.
Induction and Paralysis: Sedative and paralytic agents are administered almost simultaneously to rapidly induce unconsciousness and paralysis.
Intubation: The patient is immediately intubated once paralysis sets in, typically within seconds to a minute of drug administration.

DSI Steps:

Sedation: The patient is sedated first, usually with a dissociative agent like ketamine, allowing them to tolerate preoxygenation without agitation.
Preoxygenation: After sedation, the patient is preoxygenated in a more controlled manner, improving oxygen reserves before proceeding to intubation.
Paralysis and Intubation: Once adequate preoxygenation is achieved, a paralytic is administered, and the patient is then intubated as in RSI.

3. KEY DIFFERENCES IN APPROACH

Sedation Timing:

RSI: Sedation and paralysis occur almost simultaneously, leaving little time for any further patient preparation or intervention.
DSI: Sedation is performed first, allowing the patient to be more effectively preoxygenated while still breathing spontaneously.

Oxygenation Focus:

RSI: The priority is rapid intubation, often under the assumption that the patient has been adequately preoxygenated beforehand.
DSI: The focus is on improving oxygenation in patients who are at risk of severe hypoxia before intubation, using the sedation phase to achieve better preoxygenation.

Patient Condition:

RSI: Best suited for patients who can be adequately preoxygenated before the induction of anesthesia and paralysis.
DSI: Ideal for patients who are agitated, hypoxic, or otherwise unable to cooperate with preoxygenation due to altered mental status, respiratory distress, or other factors.

4. ADVANTAGES AND DISADVANTAGES

Rapid Sequence Intubation:

Advantages:

Quick and efficient airway control.
Reduces the risk of aspiration and airway trauma.

Disadvantages:

In patients who are not adequately preoxygenated, the risk of hypoxia during the apneic period is higher.
May be challenging in patients who are difficult to preoxygenate or who have an unstable airway.

Delayed Sequence Intubation :

Advantages:

Allows for better preoxygenation in high-risk patients.
Reduces the risk of hypoxia during intubation by optimizing oxygen levels before paralysis.

Disadvantages:

Takes longer than RSI, which may not be suitable in situations requiring immediate airway control.
Requires careful monitoring to ensure that the patient remains adequately sedated without losing airway reflexes prematurely.

5. CLINICAL CONSIDERATIONS

Patient Selection:

RSI: Preferred in situations where time is of the essence, and the patient is at immediate risk of airway compromise.
DSI: Considered in cases where there is enough time to optimize the patient’s oxygenation before paralysis, especially in patients who are at high risk for desaturation or in those who are uncooperative.

Skill and Experience:

Both RSI and DSI require advanced airway management skills. EMS providers must be adept at assessing the patient’s condition and deciding which approach is most appropriate.

CONCLUSION

Understanding the differences between DSI and RSI allows EMS providers to tailor their approach to the specific needs of the patient. While RSI is the standard for rapid airway control, DSI provides an important alternative for patients who need improved oxygenation before intubation.

The choice between the two depends on the patient's condition, the urgency of the situation, and the provider's assessment of the most effective strategy for ensuring a successful intubation.