EMS Medical Terminology - Sellick's Maneuver

EMS providers should be familiar with the Sellick Maneuver, also known as cricoid pressure, as a technique designed to reduce the risk of regurgitation and aspiration during endotracheal intubation, particularly in patients who are not fasting or at high risk of vomiting. It is an example of an eponymous medical term.

It was first described by Dr. Brian Sellick in 1961 and has been used in emergency and anesthetic situations ever since. 

However, it’s essential for EMS providers to apply the right amount of pressure and know that this technique is sometimes debated due to concerns that it may obstruct the airway or complicate intubation in some cases.

Here's what they should know:

Key Concepts

Anatomy Involved:

The cricoid cartilage is a ring-shaped structure located just below the thyroid cartilage in the neck.

When performing the Sellick Maneuver, downward pressure is applied to the cricoid cartilage, which in turn compresses the esophagus against the vertebral column, theoretically reducing the chance of regurgitation by preventing stomach contents from moving into the pharynx.

When to Use It:

Primarily used during rapid sequence intubation (RSI) to protect the airway in emergency situations, especially when there's a high risk of vomiting (e.g., trauma patients, those who have recently eaten, or have decreased consciousness).

It may also be employed during bag-valve-mask (BVM) ventilation to prevent gastric insufflation, although this use is somewhat controversial.

How to Perform It:

The provider places firm, continuous pressure using the thumb and forefinger on the cricoid cartilage (located below the Adam’s apple).

The recommended pressure is about 10 Newtons (≈1 kg of force) initially, increasing to 30-40 Newtons (≈3-4 kg of force) once the patient loses consciousness, as the risk of vomiting increases at that point.

Controversies & Limitations:

Questionable Efficacy: Studies over the years have raised doubts about the effectiveness of the Sellick Maneuver in completely preventing regurgitation or aspiration. In some cases, it may even impair ventilation or visualization of the airway during intubation, particularly in difficult airway scenarios.

Potential Complications: Incorrect application of the maneuver (too much force or misplacement of pressure) can result in airway obstruction or displacement of the esophagus laterally rather than compressing it.

Many modern airway protocols have deemphasized its routine use and instead focus on optimal intubation techniques and preparation for managing airway complications.

Training & Clinical Judgment:

EMS providers should be well-trained in applying the maneuver correctly, but also be aware that if it interferes with ventilation or intubation, it should be discontinued.

It’s essential to assess the specific patient scenario (e.g., suspected difficult airway) and weigh the benefits and risks of applying cricoid pressure.

Summary

The Sellick Maneuver was historically considered a key technique for preventing aspiration during emergency intubation, but its effectiveness is now debated. 

EMS providers should understand the anatomy, application method, and potential complications, and apply it judiciously based on the clinical situation.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Ebright, C. (2024) Unique Patient Signs: A Case Study. EMS1. Accessed May 1, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

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.

Further Reading:

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson.

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Fatolitis, N. (2022) Keys To Success For Airway Management. EMS Airway. Accessed July 26, 2024

NAEMT (2023) PHTLS: Prehospital Trauma Life Support (10th Ed). Burlington, Massachusetts: Jones & Bartlett Learning.

Nickson, C. (2024) Rapid Sequence Intubation (RSI). Life In The Fast Lane. Accessed July 26, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell.

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.

Further Reading:

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins

Fatolitis, N. (2022) Keys To Success For Airway Management. EMS Airway. https://emsairway.com/.../keys-to-success-for-airway.../... Accessed July 26, 2024

Laramie Fire Department (2024) Adult RSI Protocol. City of Laramie. https://www.cityoflaramie.org/DocumentCenter/View/29299/RSI-1-Adult-RSI-PROTOCOL? Accessed August 13, 2024

NAEMT (2023) PHTLS: Prehospital Trauma Life Support (10th Ed). Burlington, Massachusetts: Jones & Bartlett Learning.

Nickson, C. (2024) Delayed Sequence Intubation (DSI). Life In The Fast Lane. https://litfl.com/delayed-sequence-intubation-dsi/ Accessed August 13, 2024

Nickson, C. (2024) Rapid Sequence Intubation (RSI). Life In The Fast Lane. https://litfl.com/rapid-sequence-intubation-rsi/ Accessed July 26, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

EMS Medication Administration - RSI Endotracheal Intubation

EMS Providers should have a comprehensive understanding of rapid sequence endotracheal intubation (RSI) medication administration to ensure successful and safe management of patients requiring advanced airway interventions.

Here are some points they should know:

1. Indications and Goals

Indications:

• To facilitate endotracheal intubation (ETI) in patients who require definitive airway management.
• Medications administered during intubation typically include induction agents (sedatives) and neuromuscular blocking agents (paralytics) and analgesics (pain relievers).

Goals:

• Achieve rapid sedation and paralysis to facilitate smooth intubation without causing harm or distress to the patient.
• Ensure patient comfort and safety throughout the procedure.

2. Medications Used

Analgesic Agents:

• Fentanyl: EMS Providers should consider opioid administration to intubated patients, as NMBAs and sedatives do not relieve the pain associated with intubation and positive pressure ventilation (Fatolitis, 2022).

Induction Agents:

• Etomidate: Rapid onset sedative with minimal cardiovascular effects.
• Propofol: Potent sedative with rapid onset and short duration of action.
• Ketamine: Dissociative agent providing sedation, analgesia, and amnesia.
• Midazolam: Benzodiazepine used for sedation, less commonly for induction due to slower onset.

Neuromuscular Blocking Agents (NMBAs):

• Succinylcholine: Depolarizing agent for rapid paralysis.
• Rocuronium / Vecuronium: Non-depolarizing agent with longer duration of action and less side effects compared to succinylcholine.

3. Preparation and Technique

Medication Preparation:

• Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
• Calculate and prepare appropriate doses based on patient weight and condition.

Procedure Preparation:

• Ensure all equipment for intubation is ready and functional (e.g., laryngoscope, endotracheal tube, suction).
• Confirm patient positioning, secure environment, and adequate personnel for assistance.

4. Administration Techniques

Induction Agent Administration:

• Administer induction agents rapidly to achieve sedation and facilitate intubation.
• Ensure titration of medications to achieve desired sedation level without compromising hemodynamics.

Neuromuscular Blocking Agent Administration:

• Administer NMBAs after confirming adequate sedation to prevent patient awareness and facilitate intubation.
• Monitor for onset of paralysis and ensure proper ventilation during apnea phase.

5. Monitoring and Management

Monitoring:

• Continuously monitor vital signs including heart rate, blood pressure, oxygen saturation, and ECG if possible.
• Monitor level of sedation and depth of paralysis to adjust as necessary.

Management:

• Be prepared to manage potential complications such as hypotension, respiratory depression, or adverse reactions to medications.
• Have reversal agents available if needed (e.g., naloxone for opioid-induced respiratory depression).

6. Post-Intubation Care

Securing the Airway:

• Confirm proper placement of the endotracheal tube (ETT) using clinical and adjunctive methods (e.g., end-tidal CO2 monitoring).
• Secure the ETT and confirm effective ventilation.

Continued Monitoring:

• Maintain continuous monitoring of vital signs and oxygenation.
• Prepare for transport to appropriate medical facility, ensuring ongoing airway management and support.

7. Special Considerations

Pediatric and Geriatric Patients:

• Adjust medication doses and techniques based on age, weight, and physiological differences.

Difficult Airway Management:

• Be prepared for difficult intubations and have backup plans in place (e.g., alternative airway devices, surgical airway equipment).

Patient Condition:

• Consider comorbidities and potential contraindications to specific medications based on patient history.

8. Training and Proficiency

Simulation Training:

• Regular practice in simulated scenarios to maintain proficiency in intubation medication administration and airway management techniques.

Continuing Education:

• Stay updated on current guidelines, best practices, and new medications relevant to intubation and airway management.

9. Legal and Ethical Considerations

Scope of Practice:

• Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent:

• Obtain informed consent from the patient or guardian whenever possible, considering the urgency and necessity of the procedure.

Documentation:

• Accurate documentation of medication administration, intubation process, airway assessment, and ongoing patient monitoring.

Conclusion

Medication administration for RSI is a critical skill for EMS Providers performing advanced airway management. It requires proficiency in medication administration, airway assessment, and management of potential complications.

Continuous training, adherence to protocols, and effective teamwork are essential for ensuring successful patient outcomes in emergency situations.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins

Fatolitis, N. (2022) Keys To Success For Airway Management. EMS Airway. https://emsairway.com/.../keys-to-success-for-airway.../... Accessed July 26, 2024

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Nickson, C. (2024) Rapid Sequence Intubation (RSI). Life In The Fast Lane. https://litfl.com/rapid-sequence-intubation-rsi/ Accessed July 26, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell