Rapid sequence induction in the emergency depamnent Authors: Lisa Powell , RN, BN, a n d P e g g y Holt, RN, W i n n i p e g , Man i toba , C a n a d a

Rapid sequence induction Airway m a n a g e m e n t and oxygenation of the critically ill or injured pat ient is the single most important intervention in the emergency department. The t e c h - nique for planned intubation that best protects the pat ient is rapid sequence induction (RSI).

RSI is the method used to secure the airway as quickly as possible in the hemodynamically stable, spontaneously breathing emergency patient. This prevents aspiration of gastric contents and permits ongoing oxygenation. RSI induces unconsciousness and muscle relaxation that optimizes conditions for endotracheal intubation. This technique is not to be used for patients who require immediate airway

Ms. Powell is clinical nurse educator, Emergency Department, Health Sciences Centre, Winnipeg, Manitoba. Ms. Holt is a staff nurse, Surgical Intensive Care Unit, Health Sciences Centre, and a flight nurse with the Manitoba Air Ambulance, "Lifeflight" in Win- nipeg, Manitoba.

c o n t r o l (e .g . , c a r d i a c a r r e s t ) or i n t u b a t i o n w h i l e c o n -

s c i o u s .

T h i s a r t i c l e p r o v i d e s t h e E D n u r s e w i t h a s y s -

t e m a t i c a p p r o a c h to RSI ( T a b l e 1).

Indications The RSI technique is especially useful in the emer- gency depar tment in the airway managemen t of any patient who is assumed to have a full s tomach I and is, therefore, at risk for aspiration. This includes patients with (1) trauma, especially with associated head injury and suspected increased intracranial pressure, (2) al- tered level of consciousness with compromised air- way reflexes (e.g., drug overdose), and (3) agitation or

Reprints not available from authors.

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Copyright �9 1995 by the Emergency Nurses Association.

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Table 1 Sedat ing agents

Drugs Comments

Sod ium t h i o p e n t a l Dose: 3-5 m g / k g Onse t : 10-20 s e c Durat ion: 5-10 m i n

M e t h o h e x i t a l (Brevital)

Dose: 1-2 m g / k g Onse t : <1 rain Dura t ion: 5-7 m i n

K e t a m i n e Dose: 1-2 m g / k g Onse t : <30 s e c Durat ion: 10 to 20 m i n

�9 B a r b i t u r a t e - - n o a n a l g e s i c ef fec t �9 D e c r e a s e d ICP; d e c r e a s e d ce reb ra l b lood flow; d e c r e a s e d ce reb ra l me t abo l i c a n d o x y g e n

d e m a n d s �9 H y p o t e n s i o n a s a r e su l t of va sod i l a t i on a n d myoca rd i a l d e p r e s s i o n ; d e c r e a s e d o s e in

h y p o t e n s i v e or h y p o v o l e m i c p a t i e n t �9 B r o n c h o s p a s m a n d l a r y n g o s p a s m re l a t ed to h i s t a m i n e r e l e a s e �9 C o n t r a i n d i c a t e d in s t a t u s a s t h m a t i c u s a n d po rphy r i a

�9 See c o m m e n t s for s o d i u m t h i o p e n t a l �9 M a y c a u s e t w i t ch i ng , myoc lon ic jerking, or s e i z u r e s

�9 Sedat ive ; a n a l g e s i c ( twice a s p o t e n t a s morph ine ) ; a m n e s i a c ; h a l l u c i n o g e n i c (use cau t i on w i t h s t i m u l a t i n g t h e s e p a t i e n t s )

�9 Use fu l in h y p o t e n s i v e p a t i e n t b e c a u s e it i n c r e a s e s BP t h r o u g h s y m p a t h e t i c s t i m u l a t i o n �9 Bronchodi la tor , u s e f u l for a s t h m a t i c s ; s t i m u l a t e s sa l iva t ion , t h e r e f o r e is often g iven w i t h

a t rop i ne or g lycopyr ro la te to r e d u c e a i r w a y s e c r e t i o n s �9 C o n t r a i n d i c a t e d in h y p e r t e n s i o n , h e a d injury ( i n c r e a s e d CBF a n d o x y g e n c o n s u m p t i o n ) ,

o p e n eye in jur ies , g l a u c o m a , p sych ia t r i c d i so rders , d r u g a b u s e r s

ICP, In t rac ran ia l p r e s s u r e ; BP, b lood p r e s s u r e ; CBF, ce rebra l b lood flow. Da t a f rom A m p e l et al. J E m e r g M e d 1988;6:1-7; Yama- m o t o e t al. Ped i a t r E m e r g Care 1990;6:200-13; K o e n i n g KL. A n n E m e r g M e d 1992;21:47-50; a n d Nichols e t al. Go lden hour: t h e h a n d b o o k of a d v a n c e d ped ia t r i c life suppor t . St Louis: M o s b y - Y e a r Book, 1991.

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combativeness, requiring diagnostic studies (e.g., computed tomographic [CT] scan). 2 RSI is also useful in patients in whom complicated conditions such as the following coexist: pregnancy, obesity, hiatal her-

Table 2 Rapid s e q u e n c e i n d u c t i o n *

Indicat ions Specif ical ly u s e d for prevention of aspiration in situ- a t i o n s w h e n p r o t e c t i v e a i r w a y r e f l exes are a b s e n t a n d t h e p a t i e n t is a s s u m e d to h a v e a full s t o m a c h

E q u i p m e n t M a c h i n e �9 100% o x y g e n b a g - m a s k - v a l v e ven t i -

l a t ion dev ice S u c t i o n �9 Work ing suc t ion uni t w i t h both tonsi l

and eudotrachea l suct ion catheters �9 C r i c o t h y r o t o m y t r ay on s t a n d b y

M o n i t o r s �9 Cardiac m o n i t o r �9 Pu l s e o x i m e t e r

A i r w a y �9 W o r k i n g l a r y n g o s c o p e h a n d l e w i t h a s e l e c t i o n of b lade s i z e s

�9 Oral a i r w a y s of var ious s i ze �9 A se l ec t i on of e n d o t r a c h e a l tubes .

C h e c k ba l loon in tegr i ty . Place s ty l e t in a n d a t t a c h inf la t ion syr inge .

�9 Magil l forceps (to r e m o v e fore ign bod ies )

�9 S e c u r e m e n t t a p e s �9 P a t e n t l a rge -bo re IV IV

D r u g s 0 m i n

2 m i n

3 rain

A t rop ine 0.01-0.02 (chi ldren m g / k g IV <5 yr only) ( m i n i m u m

d o s e 0.15 m g / k g )

L ideca lne 1.5 m g / k g IV 0.5 m g / k g IV chi ld

d - T u b o c u r a r i n e 0.05 m g / k g IV o r

P a n c u r o n i u m 0.01 m g / k g IV A p p l y cr i co id

p r e s s u r e . Sod ium t h i o p e n t a l 3-5 m g / k g IV

o r

M e t h o h e x i t a l 1-2 m g / k g IV o r

K e t a m i n e 1-2 m g / k g IV Succ iny lcho l ine 1.5-2 m g / k g IV I n t u b a t e Conf i rm e n d o t r a -

chea l t u b e p l a c e m e n t

Re l ease cricoid p r e s s u r e

Cons ider f u r t h e r s e d a t i o n a n d para lys i s

*For e n d o t r a c h e a l i n tuba t ion , all a g e s . Th i s pro tocol d e v e l o p e d by E m e r g e n c y D e p a r t m e n t , H e a l t h Sc i ences Centre and "Lifef l ight ," M a n i t o b a Air A m b u l a n c e , Winnipeg , Mani toba , C a n a d a 1993. Consu l t a t ion w i t h regional authorit ies is adv i sed before a d a p t i n g for o ther se t t ings .

nia with reflux, acute abdomen, gastric hemorrhage, bowel obstruction, or paresis.

The systematic approach to RSI contains four basic steps: equipment, preoxygenation, induction, and intubation.

RSI is a lso u s e f u l in p a t i e n t s in w h o m c o m p l i c a t e d c ond i t i ons s u c h as t h e fo l l owing coexist : p r e g n a n c y , obes i ty , hiatal hernia w i t h reflux, acute a b d o m e n , gastr ic h e m o r r h a g e , b o w e l obs truct ion , or pares i s .

Equipment The equipment required for RSI is similar to that for any intubation. The following should be available: Machine Bag-valve-mask ventilation device connect- ed to 100% oxygen; cricothyrotomy tray on stand- by. Suction Working suction unit with both tonsil and en- dotracheal catheters. Monitors Cardiac monitor, pulse oximeter, end-tidal carbon dioxide. Airway Working laryngoscope with a selection of blades, oral airways of various sizes, endotracheaI tubes with stylet and cuff inflation syringe in place, and a patent, large-bore IV.

Drugs A nasogastric (NG) or orogastric tube should be inserted after intubation to decompress and empty the stomach. If a nasogastric tube is in place before intu- bation, the stomach contents should be aspirated and the tube left in place.

Preoxygenation The importance of preoxygenation should be empha- sized. Ideally the patient should be allowed to sponta- neously breathe 100% oxygen for 5 minutes, s How- ever, if the patient is encouraged to take four to six deep breaths, this is adequate when time is of the es- sence. 4 This action produces an adequate nitrogen washout, thus improving oxygen reserve and prevent- ing hypoxemia during the apneic period of RSI. 5 Pos- itive-pressure ventilation is detrimental in spontane-

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Firm downward pressure by assis- tant occluding esophagus with the cricoid cartilage. (Do not press on

Oa).

Es~ %

Figure 1 Cricoid pressure (Sellick maneuver). The thumb and index finger are used to press the cartilaginous cricoid ring posteriorly toward the sixth cervical vertebra, sealing the esophagus. From Horswell JL, Cobb ML, Owens MD. Anesthetic management of

the trauma victim. In: Zuidema GD, Rutherford RB, Ballinger WF, eds: The management of trauma. 4th ed. Philadelphia: WB Saunders, 1985:127-36. Used with permission.

ously breathing pat ients because it promotes gastric dis tent ion and regurgitation. 1, 3

Induction The assis t ing nurse s tands at the physic ian ' s right side facing the pa t ien t ' s head. The nurse should hold the endotracheal tube in the left hand and prepare to use the right hand to apply cricoid pressure. The goal of RSI is to secure the airway rapidly, with the least hemodynamic response to intubation, once the pa- t ient is paralyzed. Various drug combinations can be used to achieve this goal.

During the preoxygenat ion phase, the nurse pre- pares all required drugs. This process is t ime con- suming. Having the RSI drugs available in a kit is rec- ommended, because drug preparat ion is a major cause for delayed intubation. 5

At zero minutes, the following agents are consid- ered (Table 2).

A t r o p i n e , a vagolytic agent, is routinely used only for children. Atropine blocks the reflex brady- cardia associa ted with the use of succinylcholine and laryngoscopy, which is more pronounced in children younger than 5 years of age. s, 5 The usual dose is 0.01 to 0.02 mg/kg IV (minimum dose, 0.15 mg/kg). 5

L i d o c a i n e , an ant idysrhythmic agent and local anesthet ic , lowers intracranial pressure and sup- presses the cough reflex. 5 In our institution, this

drug is routinely used for any pat ient with sus- pec ted increased intracranial pressure. Laryngos- copy and tracheal intubation performed after RSI are commonly associa ted with hypertension and tachycardia. These cardiovascular responses may be blunted with lidocaine. 6 The usual dose is 1.5 mg/kg IV push (adults) and 0.5 mg/kg IV push (children).

D e f a s c i c u l a t i n g d o s e o f a n o n d e p o l a r i z i n g m u s c l e r e l a x a n t . A small dose of d-tubocurarine or pancuronium is given immediate ly after the lidocaine. The use of succinylcholine can cause muscle fascic- ulations that can increase intragastr ic pressure. There- fore a small dose of a nondepolarizing muscle relaxant is given to minimize the potential for gastric regurgi- tation. This dose is approximately one tenth of the amount required to paralyze a pat ient and is not required in children younger than 5 years of age. The usual doses are as follows: d-tubocurarine (curare), 0.05 mg/kg IV (usually 3 or 4.5 mg); pancuronium (Pa- vulon), 0.01 mg/kg IV.

At this point cricoid pressure (Sellick maneuver) is applied to prevent the likelihood of passive gastric regurgitat ion and aspirat ion during the induction of unconsciousness and paralysis. The mortality rate front aspiration of gastric contents is reported to be 70% .6

The emergency nurse applies cricoid pressure by gently placing his or her thumb and index finger on the

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c r i c o i d c a r t i l a g e a n d e x e r t i n g f i rm p r e s s u r e in t h e an-

t e r io r p o s t e r i o r d i r e c t i o n ( b a c k w a r d s ) , o c c l u d i n g t h e

e s o p h a g u s (F igure 1). C r i co id p r e s s u r e c o m p r e s s e s

t h e e s o p h a g u s a g a i n s t t h e c e rv i ca l v e r t e b r a e , w h i c h

p r e v e n t s p a s s i v e r e g u r g i t a t i o n a n d m a y i m p r o v e

v i s u a l i z a t i o n of t h e voca l co rds . 5, 6 E x c e s s i v e c r i co i d

p r e s s u r e m a y r e s u l t in c o m p r e s s i o n of t h e a i r w a y

l u m e n a n d d i s p l a c e m e n t of a n u n s t a b l e c e rv i ca l

s p i n e . 4

T h e Sell ick m a n e u v e r is m a i n t a i n e d f rom t h e on-

s e t of s e d a t i o n un t i l i n t u b a t i o n is c o m p l e t e d a n d t h e

cuf f is inf la ted . T h e p o s i t i o n of t h e e n d o t r a c h e a l t u b e

m u s t b e c o n f i r m e d b y b i la te ra l b r e a t h s o u n d au s cu l -

t a t i o n a n d t h e a p p e a r a n c e of e n d - t i d a l c a r b o n d i o x i d e

p r e s s u r e t r a c i n g on t h e c a p n o g r a p h mo n i t o r . 5 Cr ico id

p r e s s u r e d o e s n o t p r e v e n t v o m i t i n g . If v o m i t i n g

o c c u r s , t h e p a t i e n t s h o u l d b e t u r n e d to t h e s ide , cri-

c o i d p r e s s u r e s h o u l d b e r e l e a s e d , a n d t h e a i r w a y

c l ea red .

S e d a t i n g a g e n t s . T w o m i n u t e s in to t h e RSI

t e c h n i q u e , a g e n e r a l a n e s t h e t i c is g iven . T h e a g e n t s

u s e d to i n d u c e a n e s t h e s i a s h o u l d h a v e a r a p i d o n s e t

Table 3 Depolar iz ing m usc l e re laxant

Drug C o m m e n t s

Succinylcholine Dose: 1.5-2 mg/kg Onset: 30-60 sec Duration: 3-10 min

�9 Hyperkalemia: Normal to raise serum K + 0.5 mEq/L. Patients wi th myasthenia gravis, Guillain-Barr~ syndrome, or demyelinating disease may have K + rise > 10 mEq/L. In spinal cord injury this K + efflux response begins within 24 hr and lasts for 6 mo.

Burns: especially day 10 to 60 (serum K + up to 13 mEq/L). Crush or electrical injury: response lasts for >1 wk. �9 Caution wi th penet ra t ing eye injury, pat ient wi th known pseudochol inesterase de-

ficiency. �9 Contraindicated (absolute) in malignant hyperthermia. �9 Fasciculations: increased intraabdominal, intrathoracic, intracranial pressures. �9 Negative chronotrope: give wi th atropine in children <5 yr. �9 Histamine release can induce bronchospasm. �9 Muscle pain. �9 Avoid underdosing; repetit ive dosing causes parasympathet ic stimulation, resulting

in bradycardia.

/~, Potassium ion concentration. Data from Nichols et al. Golden hour: the handbook of advanced pediatric life support. St Louis: Mosby-Year Book, 1991; and Murphy-Macabobby et al. A n n Emerg Med 1992;6:664-8.

Table 4 N ondepo lar i z ing m usc l e re laxants

Drug C o m m e n t s

Curare Dose: 0.6 mg/kg Onset: 2-6 rain Duration: 45-90 min

Pancuronium Dose: 0.1-0.2 mg/kg Onset: 120 sec Duration: 45-90 min

Vecuronium Dose: 0.1-0.2 mg/kg Onset: 45-120 sec Duration: 30-90 min

Atracurium Dose: 0.4-0.7 mg/kg Onset: 2-6 min Duration: 30-45 min

�9 No vagolytic effect like pancuronium �9 Histamine release (causes hypotension and bronchospasm) �9 Slow onset �9 40% to 60% renal excretion

�9 Vagolytic effect: increased heart rate, increased blood pressure, increased carbon monoxide

�9 No effect on intracranial pressure �9 No histamine release �9 60% to 90% renal excretion (caution in renal failure)

�9 No vagolytic effect or histamine release, f ewes t cardiovascular side effects �9 Intermediate onset �9 No renal excretion �9 No contraindications

�9 Slight histamine release (hypotension + bronchospasm) �9 Ideal wi th pat ients wi th renal and liver failure

Data from Ampel et al. J Emerg Med 1988;6:1-7; Redan et al. J Trauma 1991;31:371-5; Yamamoto LG. Emerg Med Clin North Am 1991;9:611-38; Walls RM. Syllabus, 1992; and Miller RD. Anesthesia, vol 2 .3rd ed. New York: Churchill-Livingstone, 1990:1310-2.

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and shor t durat ion. Commonly u s e d IV a g e n t s inc lude (1) s o d i u m th iopenta l , 3 to 5 mg/kg; (2) m e t h o h e x i t a l (Brevital), 1 to 2 mg/kg ; and (3) ke tamine , 1 to 2 m g / kg.

S e d a t i n g a g e n t s are u s e d to ach ieve uncon- s c i o u s n e s s and apnea . Cau t ion m u s t be exe rc i s ed wi th the n o w a p n e i c pa t ien t . S t imula t ing a pa t i e n t who is still in a l ight p lane of a n e s t h e s i a m a y cause reflex v o m i t i n g or l a ryngospasm. I

The mos t c o m m o n s ide effect of t h iopen ta l is hy- po tens ion . Ke tamine is often the d rug of cho ice in t he h e m o d y n a m i c a l l y uns t ab l e pa t ien t .

S u c c i n y l c h o l i n e is a depo la r iz ing musc l e relax- ant. I m m e d i a t e l y after t he s e d a t i v e is admin i s t e r ed , a pa ra lyz ing dose of succ iny lcho l ine (1.5 to 2.0 mg/kg) is g iven (Table 3). This dose cause s r ap id glot t ic pa- ralysis1; however , the p h y s i c i a n who per forms the in- t u b a t i o n m u s t wa i t an add i t iona l 45 s e c o n d s to ensure tha t op t ima l m u s c l e para lys i s of the d i a p h r a g m has occurred .

The c o m b i n a t i o n of succ iny lcho l ine and a sed- a t ive c r ea t e s ideal cond i t ions for in tubat ion . W h e n the u s e of succ iny lcho l ine is con t r a ind ica t ed , the nondepo l a r i z i ng neu romuscu l a r b locking a g e n t s (d- tubocurar ine , pancu ron ium, vecuronium, a t racu- rium) m a y be used . T h e s e a g e n t s ac t more slowly and have longer half-l ives (Table 4). When t h e s e d rugs are u s e d i n s t e a d of succ inylchol ine , the pro- c e s s t akes longer and is t e r m e d modified rapid sequence induction.

Intubation In tuba t ion is pe r fo rmed w h e n the re is full re laxa t ion of the a i rway m u s c l e s (usually 45 s e c o n d s after admin - i s t ra t ion of succinylchol ine) . Cricoid p re s su re is ma in - t a i n e d unti l the cuff is inf la ted and the pos i t ion of the t u b e is ver i f ied by auscul ta t ion .

In tuba t ion wi th the RSI t e c h n i q u e m u s t be per- fo rmed by a skil led p h y s i c i a n b e c a u s e the pa t i en t is total ly pa ra lyzed and unconsc ious . If i n tuba t ion fails, b a g - m a s k - v a l v e vent i la t ion (with cr icoid p re s su re m a i n t a i n e d ) is jus t i f ied whi le ano ther i n tuba t ion is at- t e m p t e d or a c r i co thyro tomy is performed.

In p a t i e n t s wi th h e a d t r a u m a injuries, a i rway a n a t o m y m a y be d is tor ted , blood and sec re t ions often obs cu re t he a i rway, a n d cervical sp ine immobi l i za t ion m u s t b e ma in t a ined . 7

The e m e r g e n c y nurse d o c u m e n t s the m o d e of in tuba t ion , pe r sonne l pe r fo rming the procedure , t ype a n d dose of all m e d i c a t i o n s used, and compli-

ca t ions or diff icult ies e x p e r i e n c e d dur ing the intu- bat ion.

Summary During genera l anes thes i a , t he mos t d a n g e r o u s t ime in t e rms of a sp i ra t ion of gas t r i c con ten t s is the per iod from loss of c o n s c i o u s n e s s to t r achea l i n tuba t ion wi th a cuffed endo t r achea l tube. A rap id s e q u e n c e induc- t ion pe rmi t s comple t ion of th is p roces s in the shor tes t poss ib le t ime. 8

The t e c h n i q u e and r e c o m m e n d a t i o n s outl ined, a l though l eng thy in descr ip t ion , t ake only 3 to 5 min- u tes to e xe c u t e (Table 2). Organ iza t ion of equ ipmen t , med ica t ion , and overall env i ronmen t is the p r imary respons ib i l i ty of the e m e r g e n c y nurse. The protocol out l ined in th is ar t ic le is t ha t of one e m e r g e n c y

depa r tmen t . Other protocols m a y vary, and consul ta - t ion wi th reg iona l au thor i t i es is advised .

We thank Dr. Judith Littleford, BSc, MD, FRCP(c), Depart- ment of Anesthesia, Health Sciences Centre, Winnipeg, Manitoba, for her encouragement and assistance with this article.

References

1. Ampel L, Hott KA, Sielaff GW, Todd BS. An approach to airway management in the acutely head-injured patient. J Emerg Med 1988;6:1-7. 2. Redan J, Livingston D, Torella B J, Bush BF. The value of intubating and paralyzing patients with suspected head in- jury in the emergency department. J Trauma 1991;31: 371-5. 3. Yamamoto LG. Rapid sequence anesthesia induction and advanced airway management in pediatric patients. Emerg Med Clin North Am 1991;9:611-38. 4. Walls RM. Rapid sequence intubation: a primer of physi- cians in the emergency room. Syllabus from lecture pre- sented at Emergency Medical Meeting, St. John's, New- foundland, May 1992. 5. Yamamoto LG, Yim GK, Britten AG. Rapid sequence an- esthesia induction for emergency intubation. Pediatric Emerg Care 1990;6:200-13. 6. Morris I. Pharmacologic aids to intubation and the rapid sequence induction. Emerg Med Clin North Am 1988;6:753- 68. 7. Koening KL. Rapid-sequence intubation of head trauma patients: prevention of fasciculations with pancuronium versus minidose succinylcholine. Ann Emerg Med 1992; 21:47-50. 8. Miller RD. Anesthesia, vol 2.3rd ed. New York: Churchill- Livingstone, 1990:1310-2.

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