Airway Part 3- Rapid Sequence Intubation

The most important thing to do when preparing for RSI is to PREOXYGENATE the patient.

Step 1: Choose Your Equipment

* Miller or Mac blade? * Miller blade is straight (like the ‘L’ in miller)* Frequently used in kids* Mac blade is curved (like the ‘c’ in mac)* (Generally, this is the best choice to use on your clerkship and most common in the ED)* Tube Size?* 7.5 cuffed tube for a small adult* 8.0 cuffed tube for a big adult

Step 2: Choose your Meds

* You need both a sedative and a paralytic to perform RSI* Paralytic options are succinylcholine or rocuronium* Succinylcholine is best if you need something short acting* For example, when frequent neurologic checks are required* Rocuronium is best because it’s easy to remember (1mg/kg)* “Rocuronium Rocks”* Sedative options include ketamine, propofol, and midazolam. * My favorite is ETOMIDATE. * It is hemodynamically neutral.* Dosing is 0.3mg/kg

Step 3: Prepare Your Equipment

* Suction* Bag Valve Mask* Backup airway (ex. LMA)* Cardiac monitor* Capnography for tube placement

Step 4: DO IT

* Push the sedative* Push the paralytic* Put the blade in your LEFT hand* Open mouth with right hand* Slowly advance (holding top of blade against tongue) until you see cords* The cords will be hiding under the white, cartilaginous, tongue-like epiglottis

NOTE: It’s OK if you don’t get it. It happens and it won’t make you look bad if your form was otherwise great.

Step 5: Advance the Tube and then CLOSING STATEMENT

* Generally, you want depth to equal 3x the size of the tube* Closing statement* “Please attach capnography to confirm tube placement”* “We will need to get an X-ray, foley, OG tube and start the patient on propofol (or versed)”

CONGRATULATIONS!! THEY ARE INTUBATED!!