Emergency Steps Taken in a Rapid Sequence Intubation
Nechama Rothberger, PharmD, is a Brooklyn emergency medicine practitioner who provides clinical pharmacy services in life-threatening situations. In a 2018 nursing education lecture, Nechama Rothberger focused on “Rapid sequence intubation (RSI) and the ED nurse: A case-based approach.”
An example this type of a situation involves a 68-year-old female patient on apixaban, with a history of atrial fibrillation and chronic obstructive pulmonary disease. She becomes more altered while on a non-invasive ventilation bipap system. With the oxygen saturation level at 76 percent and bagging in process, the attending nurse identifies a risk of stroke and calls for intubation preparation.
There are several steps to RSI, starting with a preparatory phase that involves assessing the patient’s airway and assembling required drugs and equipment, while creating an airway management plan. Pre-oxygenation is performed to avoid oxygen desaturation while RSI is undertaken, which involves the administration of high-flow oxygen at the highest possible concentrations.
At 3 minutes before intubation, pre-treatment is performed with fentanyl or lidocaine, which mitigates endotracheal intubation-linked adverse effects such as elevated heart rate, arterial wall sheer stress, coughing, and other upper and lower airway spasms.
Paralysis with induction is then employed through agents such as ketamine and etomidate, which serve to create a deep state of analgesia and unconsciousness, while limited side effects.
This sets in place the necessary elements for positioning and placement of the tube in the trachea. Intubation helps ensure consistent patient breathing during sedation, anesthesia, and situations of serious illness.
An example this type of a situation involves a 68-year-old female patient on apixaban, with a history of atrial fibrillation and chronic obstructive pulmonary disease. She becomes more altered while on a non-invasive ventilation bipap system. With the oxygen saturation level at 76 percent and bagging in process, the attending nurse identifies a risk of stroke and calls for intubation preparation.
There are several steps to RSI, starting with a preparatory phase that involves assessing the patient’s airway and assembling required drugs and equipment, while creating an airway management plan. Pre-oxygenation is performed to avoid oxygen desaturation while RSI is undertaken, which involves the administration of high-flow oxygen at the highest possible concentrations.
At 3 minutes before intubation, pre-treatment is performed with fentanyl or lidocaine, which mitigates endotracheal intubation-linked adverse effects such as elevated heart rate, arterial wall sheer stress, coughing, and other upper and lower airway spasms.
Paralysis with induction is then employed through agents such as ketamine and etomidate, which serve to create a deep state of analgesia and unconsciousness, while limited side effects.
This sets in place the necessary elements for positioning and placement of the tube in the trachea. Intubation helps ensure consistent patient breathing during sedation, anesthesia, and situations of serious illness.
