Thursday, 22 September 2016

RSI

There are six separate phases of RSI.

1. Preoxygenation 
  Make sure you use your basic airway adjuncts as needed
  Consider NODSAT


2. Preparation -
pre-assessment - use "LEMON" to see if you think the tube might be difficult
equipment - use a challenge and response checklist to make sure you have remembered everything, even capnography
position patient - find a pillow!
protect c-spine

3. Premedication
    Fentanyl - onset 3 min, offset 20min
       This can be useful in patients who have a head injury

4. Paralysis and Sedation
    Paralysis  - 
    Suxamethonium - depolarising. 1 - 1.5mg/kg bolus
              10-20second onset with 3 - 5 minute offset
    or Rocuronium - 1 - 1.5mg/kg
             Hepatic and biliary excretion so longer offset time and longer onset time

   Sedation 
  Propofol - 1.5 - 2.5mg/kg induction. Maintainence at 1-4 mg/kg/hr
              15-20second onset, 5 - 10min offset
  or Ketamine 
  We don't seem to use Thio or any of the others now.

5. Passage of the ETT - this is the very tricky bit that needs some theatre time!

6. Post intubation care 
  
Complications of RSI
Failure to oxygenate - prevent by using checklist and DAS guidelines

Anaphylaxis - treat with anaphylaxis algorithm

Hypotension - turn down rate of sedation agent. Give small boluses of metaraminol or adrenaline IV to maintain BP.

Laryngospasm - oxygen, Larsens Notch
  Apply PEEP
  If this fails, paralyse and intubate (may be difficult)

Capnography
You need a good seal. If you have a poor trace this might be reflected in your capnography trace.

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