Vol. 18 •Issue 10 • Page 16
Are you up to date with the latest techniques in intubating patients during crisis situations?
When was the last time you intubated a patient? For most RTs, intubation is either feast of famine, depending on the job. Some are intubating people daily; other maybe do one every six months or so. Regardless of how often the opportunity presents itself, maintaining intubation skills and recertifying for intubation are still a much discussed topic in respiratory care, CQI and risk management circles.
American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care state: “Those who perform tracheal intubation require either frequent experience or frequent retraining.” Many questions arise from this statement. For example, how do RTs get this experience or how can they retrain effectively? And what do AHA officials consider to be “frequent”? Further, is the type of training we received in school in past years appropriate for retaining our practitioners today?
There are actually new intubation techniques gaining in popularity. Rapid sequence intubation (RSI) is one. Few RTs can do it; but being familiar with the process is critical to its success. RSI is the nearly simultaneous administration of both a neuromuscular blocking agent and a potent sedative agent to facilitate intubation.
This technique was developed by air ambulance teams that needed to quickly control the airway and minimize the risk of aspiration. Because caregivers are using a neuromuscular blocking agent, the patients can’t fight because they are paralyzed.
Increasingly the procedure is being used in many ERs and by some land-based paramedic crews treating patients in ambulances. Anesthesia staff have used this sort of technique for years. And indeed some hospitals have protocols which permit the use of paralytics and sedation to facilitate intubation in ICU and emergency settings.
Patient History Vital
But it is a bit of a change that the patient may be arriving that way in your ER. The use of these medications either in the field or in the ER makes the intubation and assessment skills of the receiving practitioner that much more critical. RTs may be summoned to assess, reposition and perhaps even replace a tube that is not correct.
Did you know that one side effect of many barbiturates is bronchospasm? We probably need to start asking in more detail what the EMTs gave the patient before we start to manipulate the airway. As practitioners, we need to refresh our knowledge of opiates and barbiturates. Even if the EMTs in your neighborhood aren’t approved to use these techniques and medications, the ER physicians are; and the doctors are being told at their meetings and in their journals that it the safest and easiest way to intubate.
When we were in school, we practiced our skills on good old Annie first. Some of us then progressed to cats for learning how to intubate babies. Others used both adult and neonatal cadavers to learn these skills if they attended RCP schools that had access to cadavers. In almost all cases, RTs go on to a rotation through the OR with anesthesia to pick up the skills they need for intubation.
When therapists get their first jobs, depending on the size of the hospital, they can expect to spend a week in the OR again as part of their orientation. This type of training will become an annual ritual as long as the therapists are in a direct patient care position. But as therapists move up in management ranks, there are fewer people watching to see if their skills are current. They are still expected to be able to intubate in a crisis, i.e., when the ER therapists can’t accomplish the job and anesthesia is not available.
Along with their responsibility for managing practitioners and for ensuring their staff members’ skills are current, managers need to self monitoring their own skills. They should not consider themselves as good simply because they have done intubations in the past. Like staff members, managers need to reschedule themselves for that anesthesia rotation. And whatever you do as a staff therapist, manager or supervisor, don’t make the mistake of thinking the same old style of training is adequate in light of some of the changes taking place.
Margaret Clark is a Georgia practitioner.
Know Your Intubation Skills. Can You Pass the Test?
a. Improves oxygenation.
b. Assists in determining tube placement.
c. Decreases the risk of regurgitation/aspiration.
d. Tests the integrity of the ET cuff.
Answer: c. Sellick’s maneuver, or cricoid pressure, depresses the cricoid cartilage firmly against the esophagus, thus decreasing the risk of regurgitation/aspiration.
2–Relaxation of the airway muscles usually occurs after administration of succinylcholine within:
a. 6 seconds.
b. 20 seconds.
c. 45 seconds.
d. 60 seconds.
Answer: c. About 45 seconds.
3–South facing ET Tubes are used for :
a. Thoracic anesthesia.
b. ENT and dental surgery.
c. For Rapid Sequence Intubation.
d. Another name for a standard ET Tube.
Answer: b. South facing tubes are used in ENT and dental surgery. They are difficult to suction through.
4–North facing ET Tubes are:
a. Nasal intubations for maxiofacial surgery.
b. A type of double lumen tube used to ventilate the left lung.
c. A type of LMA.
d. An uncuffed tube available in adult sizes.
Answer: a. North facing tubes are used for nasal intubations in maxiofacial surgery. They are difficult to suction through.
5–Rapid Sequence Intubation can be performed by:
b. ER physicians.
d. All of the above.
Answer: D All of the above in some localities.
Some Medications Used in RSI
Fentanyl–Onset within 90 seconds and duration of about 30 minutes. May decrease tachycardia and hypertension associated with intubation but may cause seizures, chest wall rigidity, skeletal muscle movements and an increased ICP. Use with caution in neonates and pediatrics.
Recommended dose is 2-3 micrograms/kg, given 1-3 minutes prior to intubation.
Thiopental–Onset 10-20 seconds and duration of five to 10 minutes. A sedative, there is no analgesic effect with thiopental. It does decrease intracranial pressure, intracerebral blood flow and cerebral oxygen consumption and is often used in head traumas.
Recommended dose: 2-5 mg/kg IV.
Methohexital–onset in less than one minute and duration of about five to seven minutes.
Recommended dose: 1-1.5 mg/kg IV.
Other hypnotic agents:
Etomidate–This older medication is still popular because of its rapid onset. It has minimal hemodynamic effects and is a favorite in trauma cases. Etomidate decreases intracranial pressure, cerebral blood flow and cerebral oxygen metabolism and is probably the most commonly used sedative in prehospital RSI.
Recommended dose: 0.2-0.4 mg/kg IV.
Propofol–Onset 10 to 20 seconds and a duration of action at 10 to 15 minutes. This is frequently used for in-hospital RSI, but it may cause hypotension.
Recommended dosage: 1-3 mg/kg IV.
Ketamine–Onset within 60 seconds, duration 5-10 minutes. Ketamine increases cardiac output, pulse rate, blood pressure, myocardial oxygen consumption, cerebral blood flow, intracranial pressure, intraocular pressure and salivary and bronchial secretions. It may cause hallucinations. It is also a bronchodilator. Children are less likely to experience side effects than are adults. Interestingly, studies show that Ketamine is the sedative of choice in asthmatic patients, particularly those with respiratory failure. Some sources recommend concurrent administration of atropine to reduce secretions.
Recommended dose for RSI in children is 2 mg/kg.
Neuromuscular blocking agents
Succinylcholine–Onset within 45 seconds, duration four to five minutes. Succinylcholine has been used for several years by anesthesia. The medication binds to acetylcholine receptors at the neuromuscular junction and paralysis occurs.
Paralysis will wane when the succinylcholine is hydrolyzed by pseudocholinesterase. Side effects include hyperkalemia, prolonged paralysis in some patients, malignant hyperthermia and increased intracranial pressure. It is recommended for EMS RSI, even though the medication must be kept refrigerated.
Recommended priming dose. 1 mg/kg. Effective dose of 1.5 mg/kg IV.
Note: Currently only the benzylisoquinoliniums and amino-steroids have been used in RSI.
Vecuronium–This amino-steroid has an onset of action within 30 seconds of initial dose, paralysis in one to four minutes and a duration 30-60 minutes.
Initial dose of about 0.1 mg/kg. High-dose vecuronium (0.28 mg/kg) is a popular choice for pediatric emergencies.
Pancuronium–This amino-steroid has an onset within 90 to 120 seconds, duration 45-90 minutes. Because of its relatively slow onset and long duration of action, Pancuronium is not recommend for EMTs performing RSI.
Recommended dose: priming dose 0.01 mg/kg IV . Effective dose: 0.1-0.2 mg/kg.
Mivacurium–This enzylisoquinolinium has an onset of action in 30 to 60 seconds, duration 15 to 20 minutes. Children may recover more quickly than adults. Potentially useful in EMS situations for RSI.
Recommended RSI dose: 0.15 to 0.3 mg/kg.
–Chart by Margaret Clark