Lesson 3 of 16
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Rapid Sequence Intubation (RSI): 7 P’s of Intubation

  1. Preparation
  2. Preoxygenation
  3. Pretreatment
  4. Paralysis with Induction
  5. Protection and Positioning
  6. Placement
  7. Post-intubation management

Preparation (~Zero minus 10 min)

  • Before an intubation, the patient is assessed for difficulty and a plan of action is made to prepare all necessary drugs and supplies.
  • At least one good intravenous line should be established before continuing with RSI in order to avoid any mishaps during this process.
  • Items and situations to consider during preparation:
    • ETT, stylet, blades, suction, BVM
    • Cardiac monitor, pulse oximeter, ETCO2
    • One ( preferably two ) iv lines
    • Drugs
    • Difficult airway kit including cricothyrodotomy kit
    • Patient positioning

Preoxygenation ( ~ Zero minus 5 min)

  • Preoxygenation is a technique that involves administering 100% oxygen for 3 minutes of normal tidal volume breathing in order to establish an adequate oxygen reservoir.
  • Manual ventilation prior to intubation should be reserved for patients who are hypoxic (saturation <91 percent).
    • Slow rate 8 bag/mask ventilations to avoid over inflation of lungs and stomach which increase the risk of aspiration.
  • This allows the patient to have 3-8 minutes of safe apnea before they began desaturating into dangerous levels without needing bagging assistance during RSI (rapid sequence intubations).

Pretreatment ( ~ Zero minus 3 min)

  • Laryongoscopy can activate coughing and gagging.
  • Patients that have increased risk of the unwarranted hemodynamic changes with RSI:
    • Infants: Bradycardia
    • Adults: High BP, Bronchospasm, Increase ICP and Heart Rate

  • In highly emergent cases it is not worth it to wait for pretreatment and pretreatment can be judiciously omitted.
    • Over time we have seen how insignificant it has been to make sure that a pre-treatment approach helps optimize our patients’ physiology prior to any attempts of laryngoscopies/trachael intubations.

    Paralysis with Induction ( Zero)

    • When inducing anesthesia, a potent sedative agent is administered by rapid intravenous push in a dose capable of producing unconsciousness rapidly. This will be immediately followed by an intubating dose of NMBA. It’s usual to wait 45 seconds from when the succinylcholine was given and 60 seconds after rocuronium has been given for sufficient paralysis to occur so that surgery can begin safely with minimal issues.

    Protection and Positioning ( Zero plus 30 s)

    • Patients should be positioned for intubation as they lose consciousness. Usually, that means flexing the neck and head downwards with cervical spine extension. However, a full sniff position is best if DLs are used to keep their necks extended.

    Placement ( Zero plus 45 s)

    • After you administer the NMBA, a patient should become relaxed enough to be able to insert an ETT. Test for this by moving their mandible and testing if they retain muscle tone. Then, place the ETT during glottic visualization with laryngoscopy before confirming placement of the tube.

    Post-intubation Management ( Zero plus 2 mins)

    • Once tube placement has been confirmed using ETCO2, place the patient on continuous capnography. Avoid long-acting neuromuscular blockers (e.g., pancuronium) and focus instead on optimal management with opioid analgesics and sedatives to facilitate mechanical ventilation if available.