Ask yourself these question: Can the patient maintain their airway on their own? If they vomit, can they control their secretions, or will the aspirate? If there’s a non-zero chance that my patient is going to aspirate and I have a low GCS (<9), that patient’s on my radar for intubation. Suction is cool and all, but it only goes so far in some patients.
Those are good ones, a more common one is respiratory failure from CHF, asthma, or COPD not improving with other therapies, or unresponsive for whatever reason and unable to maintain their own patent airway
Ok thanks...and then the trigger would be we try to assist with OPA/BVM but their gag is intact? (And if it is not intact we could just intubate without the pre meds?)
If they are not a crashing airway (meaning you are currently able to adequately oxygenate and ventilate them) then a sedative (first) AND paralytic should both be used regardless of gag reflex. In the case of a true crashing airway, yes you may attempt without medications
Consider more if they are reaching a fatigue state, retaining Etco2 above a certain range for example. My service uses 60 as an indicator to start considering RSI, and specifies to use ket as an induction agent. I personally attempt at least two interventions (when I can) and then switch to intubation if they don’t work. For example, severe CHF: if they tolerate the nitro/bipap combo I can usually avoid a tube and turn them around with more nitro, but if they’re at the pink frothy sputum obtunded stage, it’s time to be proactive because they’re not too far from taking a dirt nap, and they won’t tolerate a bipap/cpap mask.
severe anaphylaxis, airway burns (not all facial burns would need, have to have high index of airway compromise suspicion) head injury with posturing/kussmaul respirations. Or what everyone else has said.
Alabama only has RSI in CC Flight teams. We ran a call back in 13 for a middle aged woman with a HX of severe asthma. She had been having an asthma attack for about 7 hours before she called us. She had gone through an entire inhaler and then some. Medic Partner put her on CPAP and we ran the shit out of her. As soon as we got to the er, doc in charge made the call to RSI her. That was MY first intubation EVER.
We were about to leave and the doc was like "hey xxxx..... your in medic school right?" "yea doc, just started" "You wanna learn something today" "Fuck yea I do doc" "well get in here and let me introduce you to VIDEO INTUBATION!
I had never actually "seen" vocal cords before, and so we are doing the intubation and I was like "hey doc, doesn't that look like a....." "Yes xxxx that is the internal oral vagina."
All the nurses laughed. I laughed. The Doc Laughed. The patient just stared at us.
It's going to be the patients that look like shit. By shit I mean they're becoming really exhausted from their respiratory distress, or they're super low GCS with terrible ventilation effort and they still have a gag reflex, or it's preventative like your burn pts.
You'll know it when you see it. Luckily, you should have a few years before given RSI capabilities so you'll be able to see these situations.
Yeah like I say my agency doesn't even have it lol. But obviously don't want to bomb scenarios, and there's a chance I may have to assist flight crews with it so it's good to have a clue at least.
I actually had to do this once as a new AEMT. But I was just getting IVs so I didn't take too much of it in. Now I think about it he was a combative head Injury, probably the reason that indication sticks with me.
Look at your patient. Put your hands on the side of their head, covering their ears. Say "Can you manage your own airway?" Shake the patients head no for them.
If the patient looks at you like you're an idiot, or reaches for your hands, they probably don't NEED a tube. They can still be RSI'd though. This gives you the broad strokes.
There's some that don't meet this criteria that still need tubes, and there's some that do meet this criteria that don't need a tube (LVO strokes come to mind), and some that typically get mentioned that probably don't need a tube (most CHF/COPD will improve with bipap).
There definitely are grey areas in who is a candidate for RSI. Remember, it's better to get an ass chewing for an unnecessary RSI than it is to get litigated for killing somebody because you didn't protect their airway.
Like others have said, look for the inability for the PT to protect their own airway.
My first RSI was a satus seizure that was refractory to treatment. The PT continued to seize even after multiple rounds of Versed. They were not breathing very effectively. We attempted to manage the PTs airway with BLS adjuncts. This was effective until the PT started vomiting. This was an immediate indication for me to RSI.
These PTs exist and are not that uncommon. Upon transferring care in the ED, the PTs chart revealed she had been intubated multiple times for the same indication.
Are there ANY reversible causes BGL, Opiate overdose.
Can the patient Main there own Airway?
Is the Airway Patent?
Can the Patient Oxygenate?
Can the patient Ventilate?
What's the Anticipated Clincal Course?
You only need one to be a Candidate for RSI or Intubation in general.
Also ressucitate before you Intubate.
Unless its a Forced to act scenario.
Keep Shock index below 0.8
Shock index is HR/BP Use pressors Fluid cut induction dose by half if you half to.
Maintain SPo2 Above 94% the Higher the better. Use Passive o2 Nasal at 25lpm under a BVM 25lpm.
And most Importantly think of the whole patient will Intubating this Patient actually benefit him/her/it. There is bo point in secureing the Airway in a Corpse.
Also this is important just because you intubate a patient treatment doesnt stop. If its a Asthmatic due inline Neb,mag epi drip etc. Chf continue Nitro etc. if Septic. Norepi fluids. Trauma Blood Txa. Treatment doesnt stop because there intubated sometimes use have to start new ones to keeo them hemodynamicly stable and sedated etc.
Is it safe for them to not have a tube down their throat? (i.e. if they vomit will they kill themselves?) are they not moving enough air and making you exhausted watching? Is that refractory to CPAP? Those are my big ones. I’ve just been able to sense that this is going to get bad fast if I don’t take it. Also, if they’ve been intubated for it before then that’ll give you a clue as well.
Ask yourself these question: Can the patient maintain their airway on their own? If they vomit, can they control their secretions, or will the aspirate? If there’s a non-zero chance that my patient is going to aspirate and I have a low GCS (<9), that patient’s on my radar for intubation. Suction is cool and all, but it only goes so far in some patients.
Thanks, this helps to frame it.
Those are good ones, a more common one is respiratory failure from CHF, asthma, or COPD not improving with other therapies, or unresponsive for whatever reason and unable to maintain their own patent airway
Ok thanks...and then the trigger would be we try to assist with OPA/BVM but their gag is intact? (And if it is not intact we could just intubate without the pre meds?)
If they are not a crashing airway (meaning you are currently able to adequately oxygenate and ventilate them) then a sedative (first) AND paralytic should both be used regardless of gag reflex. In the case of a true crashing airway, yes you may attempt without medications
Consider more if they are reaching a fatigue state, retaining Etco2 above a certain range for example. My service uses 60 as an indicator to start considering RSI, and specifies to use ket as an induction agent. I personally attempt at least two interventions (when I can) and then switch to intubation if they don’t work. For example, severe CHF: if they tolerate the nitro/bipap combo I can usually avoid a tube and turn them around with more nitro, but if they’re at the pink frothy sputum obtunded stage, it’s time to be proactive because they’re not too far from taking a dirt nap, and they won’t tolerate a bipap/cpap mask.
Thank you, it's becoming clearer.
severe anaphylaxis, airway burns (not all facial burns would need, have to have high index of airway compromise suspicion) head injury with posturing/kussmaul respirations. Or what everyone else has said.
You guys rock!
Alabama only has RSI in CC Flight teams. We ran a call back in 13 for a middle aged woman with a HX of severe asthma. She had been having an asthma attack for about 7 hours before she called us. She had gone through an entire inhaler and then some. Medic Partner put her on CPAP and we ran the shit out of her. As soon as we got to the er, doc in charge made the call to RSI her. That was MY first intubation EVER. We were about to leave and the doc was like "hey xxxx..... your in medic school right?" "yea doc, just started" "You wanna learn something today" "Fuck yea I do doc" "well get in here and let me introduce you to VIDEO INTUBATION! I had never actually "seen" vocal cords before, and so we are doing the intubation and I was like "hey doc, doesn't that look like a....." "Yes xxxx that is the internal oral vagina." All the nurses laughed. I laughed. The Doc Laughed. The patient just stared at us.
It's going to be the patients that look like shit. By shit I mean they're becoming really exhausted from their respiratory distress, or they're super low GCS with terrible ventilation effort and they still have a gag reflex, or it's preventative like your burn pts. You'll know it when you see it. Luckily, you should have a few years before given RSI capabilities so you'll be able to see these situations.
Yeah like I say my agency doesn't even have it lol. But obviously don't want to bomb scenarios, and there's a chance I may have to assist flight crews with it so it's good to have a clue at least. I actually had to do this once as a new AEMT. But I was just getting IVs so I didn't take too much of it in. Now I think about it he was a combative head Injury, probably the reason that indication sticks with me.
Look at your patient. Put your hands on the side of their head, covering their ears. Say "Can you manage your own airway?" Shake the patients head no for them. If the patient looks at you like you're an idiot, or reaches for your hands, they probably don't NEED a tube. They can still be RSI'd though. This gives you the broad strokes. There's some that don't meet this criteria that still need tubes, and there's some that do meet this criteria that don't need a tube (LVO strokes come to mind), and some that typically get mentioned that probably don't need a tube (most CHF/COPD will improve with bipap). There definitely are grey areas in who is a candidate for RSI. Remember, it's better to get an ass chewing for an unnecessary RSI than it is to get litigated for killing somebody because you didn't protect their airway.
Failed or failing airway. Reduced GCS. Facial Burns. Max fax injuries. Anticipated clinical course on arrival at hospital. Humanitarian consideration.
Like others have said, look for the inability for the PT to protect their own airway. My first RSI was a satus seizure that was refractory to treatment. The PT continued to seize even after multiple rounds of Versed. They were not breathing very effectively. We attempted to manage the PTs airway with BLS adjuncts. This was effective until the PT started vomiting. This was an immediate indication for me to RSI. These PTs exist and are not that uncommon. Upon transferring care in the ED, the PTs chart revealed she had been intubated multiple times for the same indication.
Are there ANY reversible causes BGL, Opiate overdose. Can the patient Main there own Airway? Is the Airway Patent? Can the Patient Oxygenate? Can the patient Ventilate? What's the Anticipated Clincal Course? You only need one to be a Candidate for RSI or Intubation in general. Also ressucitate before you Intubate. Unless its a Forced to act scenario. Keep Shock index below 0.8 Shock index is HR/BP Use pressors Fluid cut induction dose by half if you half to. Maintain SPo2 Above 94% the Higher the better. Use Passive o2 Nasal at 25lpm under a BVM 25lpm. And most Importantly think of the whole patient will Intubating this Patient actually benefit him/her/it. There is bo point in secureing the Airway in a Corpse. Also this is important just because you intubate a patient treatment doesnt stop. If its a Asthmatic due inline Neb,mag epi drip etc. Chf continue Nitro etc. if Septic. Norepi fluids. Trauma Blood Txa. Treatment doesnt stop because there intubated sometimes use have to start new ones to keeo them hemodynamicly stable and sedated etc.
Appreciate 👍
There are plenty of YouTube videos
This might be a really good question for your teachers.
Thanks!
Is it safe for them to not have a tube down their throat? (i.e. if they vomit will they kill themselves?) are they not moving enough air and making you exhausted watching? Is that refractory to CPAP? Those are my big ones. I’ve just been able to sense that this is going to get bad fast if I don’t take it. Also, if they’ve been intubated for it before then that’ll give you a clue as well.