Summit County Ambulance Clinical Protocols

217 Pages·2014·5.7 MB·English

SUMMIT COUNTY
AMBULANCE SERVICE
ADULT RAPID SEQUENCE
INTUBATION PROTOCOLS
Version 1.0
THESE PROTOCOLS ARE EFFECTIVE MARCH 19, 2014
TABLE OF CONTENTS
1010 WHEN TO CONSIDER RAPID SEQUENCE INTUBATION
1020 ADULT RAPID SEQUENCE INTUBATION
1030 DIFFICULT AIRWAY
1040 FAILED AIRWAY
1050 POST ADULT RAPID SEQUENCE INTUBATION MANAGEMENT
1060 POTENTIAL ADVERSE EVENT MANAGEMENT
1070 DETERMINING DIFFICULT BAG/MASK VENTILATIONS (MOANS)
1080 DETERMINING DIFFICULT LARYNGOSCOPY/INTUBATION (LEMON)
1090 KETAMINE
1100 ANECTINE (SUCCINYCHOLINE)
1110 RSI CHECKLIST AND DOSING CARD
1010 WHEN TO CONSIDER RAPID SEQUENCE INTUBATION

Patient at risk of
airway/ventilation
compromise
Perform BLS
airway
management
Address
Patient is likely to improve with
reversible
time and/or treatment. This may
causes
include:
• Hypoglycemia
• Opiate overdose
• Postitcal after seizure
• Bronchospasm
Patient
Yes
improves?
Transport and monitor for
No
changes
Some patients may not improve
Is prognosis
No with treatment, however their
poor?
presentation is not alarming and
they are unlikely to deteriorate
rapidly. This may include:
• Alcohol intoxication
Yes
• Trauma with airway
managed
• Bronchospasm, without
deterioration
Establish advanced Can establish
airway (intubation or Yes advanced airway
King supraglottic) without RSI?
No
Consider RSI
1020 ADULT RAPID SEQUENCE INTUBATION
Adult Rapid Sequence Intubation B IV I P Adv
Standing order X
Second attendant X X
General Information
A. RSI is meant to facilitate orotracheal intubation of patients requiring immediate control of their airway when
other methods of airway control are either inappropriate or less advantageous.
B. Considerations for RSI include any patient that suffers a threatened airway, requires ventilatory assistance, or
is at imminent risk of suffering airway or ventilatory compromise.
C. RSI is the tool of choice (when no contraindications exist) for airway management of non-obtunded patients
with a gag reflex and patients suffering from trismus.
Indications:
A. Patient must be ≥ 13 years old or longer than the Broselow-Luten tape
B. GCS ≤ 9 with intact gag reflex and potential for airway compromise
C. Combative patient with clear need for intubation (inability to maintain airway or ventilate by any other method)
D. Trismus/clenched jaw
E. Respiratory failure or insufficiency
F. Airway injury (swelling or obstruction)
Contraindications:
A. Known hypersensitivity to any medications used for RSI
B. Patients that can be orally intubated without the use of RSI
C. Patients that cannot be adequately ventilated with bag-valve mask
D. Patients considered difficult laryngoscopy/intubation candidates
E. Hyperkalemia
1. Succinylcholine should be administered with GREAT CAUTION to patients with hyperkalemia because
in these patients succinylcholine may induce serious cardiac arrhythmias or cardiac arrest.
Technique:
A. Confident you will be able to manage patient’s airway with BVM
B. Confident you will be able to perform laryngoscopy and intubate this patient
C. Check blood sugar
D. Apply monitors (continuous ECG, HR, BP, SaO , ETCO )
2 2
1. Obtain complete set of vital signs
2. Continuous monitoring with waveform ETCO capnography is mandatory during RSI
2
E. Pre-oxygenate with 100% oxygen for approximately 3 minutes or 8 vital capacity breaths with BVM or NRB
F. Ensure patent vascular access (2 IV or IO preferred)
G. Prepare and test equipment:
1. BVM with high flow O2
2. Suction on and working
3. King Vision laryngoscope on and working
4. ETT balloon tested
5. If using non-channeled blade, ETT placed on rigid stylet
6. Airway adjuncts (e.g. Bougie) available
7. Tube securing device ready
8. Rescue device immediately available
9. Cricothyrotomy equipment immediately available
H. Prepare / draw up amount to be administered / label medications
1. Verify medications at least 3 times before administration (5 Patient Rights)
I. Thoughtful pause – Complete Pre-RSI checklist
J. Administer ketamine
K. Administer succinylcholine
L. Perform endotracheal intubation
1. LIMIT ATTEMPTS TO 30 SECONDS OR DROP IN SPO <90% – oxygenate with BVM for 60 seconds
2
between attempts
2. NO MORE THEN 2 ATTEMPTS – move on to rescue airway
M. Confirm tube placement
N. Restrain patient’s arms and legs to prevent extubation
O. Prevent excessive movement of head (consider LSB and c-collar)
P. Go to Post Rapid Sequence Intubation Management Protocol
Special Notes
A. Required notification after procedure is performed:
1. Clinical Practice Supervisor and AOC – Immediately after completion of the call
2. Medical Director – Within 24 hours after completion of the call
3. Colorado Department of Public Health and Environment Emergency Medical and Trauma Section –
Colorado EMS RSI Case Report submitted within 7 days
1030 DIFFICULT AIRWAY

Difficult airway predicted
Transport time BLS airway management
No
>10 minutes? Load and go
Best attempt at intubation
Go to Post Advanced Airway
Successful? Yes
Management
No
2nd attempt
Yes
successful?
No
Go to Failed Airway algorithm
1040 FAILED AIRWAY
2 failed intubation attempts
after induction/paralysis
Place King Airway
Go to Post Adult RSI
Successful? Yes
Managment
No
BLS airway management
Effective Go to Post Adult RSI
Yes
ventilations? Managment
No
Perform cricothyrotomy
1050 POST ADULT RAPID SEQUENCE INTUBATION MANAGEMENT
Post Adult Rapid Sequence Intubation Management B IV I P Adv
Standing order X
Second attendant X X
Tube Placement Confirmation
A. Utilize all the following to confirm placement (both endotracheal intubation and King airway):
1. For endotracheal intubation, visualizing the endotracheal tube passing through the cords
2. Continuous end tidal CO2 waveform capnography – square waveform that exists for 6 breaths
3. Auscultation over both lungs and epigastrium
4. Visible chest rise and fall
B. Re-confirm at the following intervals:
1. Whenever the patient is moved
2. With the transfer of care at the receiving facility
Patient Monitoring
A. Continue patient monitoring
1. Continuous ECG
2. Heart rate
3. Blood pressure
4. Continuous pulse oximetry
5. Continuous end tidal CO capnography
2
B. Continuous monitoring with end tidal CO waveform capnography monitoring is mandatory
2
Maintenance of Sedation and Analgesia
A. Consider ketamine
1. Administer 10 minutes after successful RSI and first administration of induction dose
2. Dose
a. Refer to ketamine protocol for dosing
B. Consider Versed (midazolam)
1. After successful RSI and ketamine induction administration
2. Contraindication
a. Hypotension
3. Dose
a. 2 mg IV up to 2 times
Maintenance of Paralytic
A. Vecuronium bromide
1. Consider maintenance paralytic if time between RSI and arrival at the hospital will be longer than 10
minutes
2. Concentration
a. 10 mg/10 ml (1 mg/ml)
3. Dose
a. 0.1 mg/kg IV
1060 POTENTIAL ADVERSE EVENT MANAGEMENT
Hypotension
A. Hypotension is common in the post intubation period and is often caused by diminished venous blood return
as a result of the increased intrathoracic pressure that accompanies positive pressure ventilation or
exacerbation of the hemodynamic effects some induction agents
B. Usually self-limiting; treat with IV fluids
Bradycardia
A. Verify hypoxia is not the cause of the bradycardia
B. Consider atropine 0.5 mg IV
1. Profound bradycardia and cardiac arrest can occur during intubation of critically ill patients
2. Atropine should be readily available when intubating
Hypertension
A. Do not attempt to treat in the field; transport patient
Tachycardia
A. Do not treat in the field; transport patient
1070 DETERMINING DIFFICULT BAG/MASK VENTILATIONS (MOANS)
General Information
A. When performing rapid sequence intubation you must be confident that you can ventilate the patient with a
bag-valve mask
Indicators of Difficult Bag/Mask Ventilations (mnemonic MOANS)1

MOANS
M
ask Seal Bushy beards, crusted blood on face, facial trauma
O
besity/
Pregnant patients in 3rd trimester, airway edema, foreign body
O
bstruction
A
ge >55 years old
N Consider leaving dentures in for bag-valve mask ventilations, remove for
o teeth
intubation
S Asthma, COPD, ARDS, pulmonary edema, advanced pneumonia, reduced
tiff Lungs
pulmonary compliance

1 (Walls)