- Rapid sequence induction
Rapid Sequence Induction (RSI) is an advanced medical procedure, designed for the expeditious
intubation of the trachea of a patient. RSI is generally used for patients who have an increased risk of aspirating stomach contents into the lungs due to a current disease process.Technique
The technique, RSI, strictly refers to the sedation and induction of paralysis prior to an
intubation procedure. The technique is a quicker form of the process normally used to "induce" a state of generalanesthesia . The difference between an RSI and standard anaesthetic induction is that the anaesthetist does not wait to see the effect of the drugs. It uses drugs to rapidly allow anendotracheal tube to be placed between the vocal cords, while the cords are being visualized via alaryngoscope . The neuromuscular blocking agents interfere the patient's smooth muscles in theoropharynx ,larynx , anddiaphragm . Once theendotracheal tube has been passed between thevocal cords , a cuff is inflated around the tube in thetrachea and the patient can then be artificially ventilated. RSI involves pre-oxygenating the patient with a tightly-fitting oxygen mask, followed by the sequential administration of pre-determined doses of a hypnotic drug and a rapid-actingneuromuscular blocker . Hypnotics used includethiopental ,propofol andetomidate .Neuromuscular-blocking drugs used includesuxamethonium (also calledsuccinylcholine ) androcuronium . [http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijeicm/vol4n1/rapid.xml#documentHeading-VI.Pharmacology Rapid Sequence Induction for Prehospital Providers ] ] Other drugs may be used in a "modified" RSI. When performing endotracheal intubation, there are several adjunct medications available. No adjunctive medications, when given for their respective indications, have been proven to improve outcomes. [David T. Neilipovitz, Edward T. Crosby: "No evidence for decreased incidence of aspiration after rapid sequence induction", in: "Canadian Journal of Anesthesia" 54, 9, 2007, S. 748-764 [http://www.ncbi.nlm.nih.gov/pubmed/17766743 Abstract] , http://www.cja-jca.org/cgi/content/full/54/9/748 ]Opioid s such asalfentanil orfentanyl may be given to attenuate the responses to the intubation process (tachycardia and raisedintracranial pressure ). This is supposed to have advantages in patients withischemic heart disease and those with intra-cerebral haemorrhage (e.g. after traumatic head injury or stroke). Lidocaine is also theorized to possibly decrease a rise in intracranial pressure during laryngoscopy, although this remains controversial and its use varies greatly. Atropine may be used by many physicians to prevent a reflex bradycardia during laryngoscopy, especially in young children and infants.Requirements
The clinician that performs RSI must be skilled in
intubation . Failure to intubate means needing to ventilate by mask. In case the patient's airway may still not be secured with appropriateairway management means certain death.The clinician that performs RSI must be knowledgeable about the drug administered. The clinician must understand the to time onset of action of a drug and the required dosage. Otherwise, the clinician risks paralyzing a fully conscious patient. The clinician must also be aware of possible side effects of the drugs such as
malignant hyperthermia . The clinician must use sound judgment in selecting which drug is to be used and the amount to be used.Meticulous preparation and planning is necessary. Back-up plans must be in place. Plans may include the option to move to a non-visualized such as the
combitube , orlaryngeal mask airway . A mandatory emergency back-up plan is an emergencycricothyrotomy This procedure is extremely dangerous. A clinician removes all ability of the patient to breathe or to maintain a patent airway. For this purpose, most prehospital paramedic ambulances are required to have two paramedics in the patient compartment when performing this procedure.
Mnemonic
A mnemonic for performing RSI is the seven Ps
# Preparation-- Prepare all necessary equipment, drugs and back-up plans
# Preoxygenation-- with 100% oxygen
# Premedication-- depending on the patient, just the hyponotic agent
# Paralyze--suxamethonium orrocuronium
# Pass the tube-- Visualize the tube going through the vocal cords
# Proof of placement-- Using reliable confirmation method
# Post intubation care-- Secure the tube, ventilateConclusion
This procedure is usually performed by
Anesthesiologist in Surgery and by Emergency Room Dcotors in the emergency department. It is also performed in the prehospital setting. The prehospital clinician that performs this procedure is a person trained to theParamedic level.References
External links
* cite journal
last = Pousman
first = Robert M.
authorlink =
title = Rapid Sequence Induction for Prehospital Providers
journal = The Internet Journal of Emergency and Intensive Care Medicine
volume = Volume 4
issue = Number 1
publisher = Internet Scientific Publications, LLC
date =2000
url = http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijeicm/vol4n1/rapid.xml#documentHeading-VI.Pharmacology
format =HTML
issn = 1092-4051*
*
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